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Florida Administrative Code § 59A-5.012

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“Medical records under the Agency for Health Care Administration regulations”  

Each ambulatory surgical center must maintain patient medical records in a confidential and secure manner. Each medical record must contain the following information:

1. Identification data;

2. Chief complaint;

3. Present illness;

4. Past personal history;

5. Family medical history;

6. Physical examination report;

7. Provisional and pre-operative diagnosis;

8. Clinical laboratory reports;

9. Radiology, diagnostic imaging, and ancillary testing reports;

10. Consultation reports;

11. Medical and surgical treatment notes and reports;

12. The appropriate informed consent signed by the patient;

13. Record of medication and dosage administered;

14. Tissue reports;

15. Physician orders;

16. Physician and nurse progress notes;

17. Final diagnosis;

18. Discharge summary; and

19. Autopsy report, if appropriate.

Related laws:

Florida Statutes § 395.001

Florida Statutes § 395.1055

Florida Statutes § 395.3025

Current as of June 2015