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Florida Administrative Code § 59A-8.022

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

Home health agencies must maintain clinical records for each patient. Patient information may only be disclosed with the patient’s consent. If the patient transfers to another home health agency, a copy of his record must be transferred at his request.

Clinical records must contain the following:

  • Source of referral;
  • Physician, physician assistant or advanced registered nurse practitioner’s verbal orders;
  • Assessment of the patient’s needs;
  • Statement of patient or caregiver problems and ability to provide interim services;
  • Patient identifying information;
  • Plan of care;
  • Clinical and service notes;
  • Home visits to patients for supervision of staff providing services;
  • Reports of case conferences;
  • Reports to physicians, physician assistants, or advanced registered nurse practitioners; and
  • Termination summary.

Related laws:

Florida Statutes § 400.491

Florida Statutes § 400.494

Florida Statutes § 400.497

Current as of June 2015