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Florida Administrative Code § 59A-13.014
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“Medical record under the Agency for Health Care Administration regulations”
Prescribed pediatric extended care centers must maintain a medical record for each child. Each record must contain the following information:
(a) A medical plan of treatment and a nursing protocol of care.
(b) All details of the referral, admission, correspondence and papers concerning the child.
(c) Physician orders.
(d) Flow chart of medications and treatments administered.
(e) Concise, accurate information and initialed case notes reflecting progress toward achievement of care goals or reasons for lack of progress.
(f) Documentation of nutritional management and special diets, as appropriate.
(g) Documentation of physical, occupational, speech and other special therapies.
Related laws:
Current as of June 2015