1. (1) Each center shall establish processes to obtain, manage, and utilize information to enhance and improve individual and organizational performance in patient care, management, and support processes. Such processes shall:

   1. (a) Be planned and designed to meet the center’s internal and external information needs;
   2. (b) Provide for confidentiality, integrity and security;
   3. (c) Provide education and training in information management principles to decision-makers and other center personnel who generate, collect, and analyze information; and,
   4. (d) Provide for information in a timely and accurate manner;
2. (2) Each center shall have a medical records service, patient information system or similarly titled unit with administrative responsibility for medical records.
3. (3) The administrator shall appoint in writing a qualified person responsible for the medical records service. This person shall meet the qualifications established for this position, in writing, by the governing board.
4. (4) A current job description delineating duties and responsibilities shall be maintained for each medical records service position.

5. (5) The medical records service shall:

   1. (a) Maintain a system of identification and filing to ensure the prompt location of a patient’s medical record. Patient records may be stored on electronic medium such as computer, microfilm or optical imaging;
   2. (b) Maintain a current and complete medical record for every patient admitted to the center.
   3. (c) All clinical information pertaining to the patient’s medical treatment shall be centralized in the patient’s medical record.

   4. (d) Ensure that each medical record shall contain the following, as appropriate to the service provided:

      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.

   5. (e) Ensure that:

      1. Operative reports signed by the surgeon shall be recorded in the patient’s record immediately following surgery or that an operative progress note is entered in the patient record to provide pertinent information; and,

      2. Postoperative information shall include vital signs, level of consciousness, medications, blood or blood components, complications and management of those events, identification of direct providers of care, discharge information from post-anesthesia care area.

   6. (f) Index, and maintain on a current basis, all medical records according to surgical procedure and physician.

Rulemaking Authority 395.1055 FS. Law Implemented 395.1055, 395.3025 FS. History–New 6-14-78, Formerly 10D-30.12, 10D-30.012, Amended 11-13-95, 9-17-14.