Effective date: 5/4/2015
The licensed nurse responsible for the delivery of skilled patient care shall maintain a clinical record, pursuant to section 400.497(8), F.S., for each patient receiving nursing services in the home that shall include, at a minimum, the following:
Terms Used In Florida Regulations 59A-18.012
- Caregiver: means a registered nurse, licensed practical nurse, certified nursing assistant, home health aide, homemaker or companion that is referred by a nurse registry to provide services to patients. See Florida Regulations 59A-18.002
- Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
- Independent Contractor: means a person who contracts through a referral from a nurse registry. See Florida Regulations 59A-18.002
- Plan of treatment: means written plan of care and treatment, including a medical plan of treatment, signed within 30 days by the physician, advanced practice registered nurse, or physician assistant to assure the delivery of safe and adequate care provided by a licensed nurse to a patient in the home. See Florida Regulations 59A-18.002
(2) Before information can be released, an authorization for such release must be dated and signed by the patient, caregiver, or guardian;
(3) Plan of treatment as required in section 400.506(13), F.S.;
(4) Clinical and service notes, signed and dated by the nurse providing the service which shall include:
(a) Any assessments by a registered nurse;
(b) Progress notes with changes in the person’s condition;
(c) Services provided;
(d) Observations; and,
(e) Instructions to the patient and caregiver;
(5) Reports to physicians;
(6) Termination summary including:
(a) The date of the first and last visit;
(b) The reason for termination of services;
(c) An evaluation of established goals at time of termination;
(d) The condition of the patient at the time of termination of services; and,
(e) The referral for additional services when the patient requires continuing services.
(7) Each nurse registry shall keep clinical records received from the independent contractor licensed nurse for 5 years following the termination of service. Retained records can be stored as hard paper copy, microfilm, computer disks or tapes and must be retrievable for use during unannounced surveys.
(8) The nurse registry is not obligated to review patient or client records per section 400.506(20), F.S., but the nurse registry is not prohibited from reviewing records and may do so. In the event of violation of state law which comes to the attention of the nurse registry, the nurse registry shall take the actions specified in section 400.506(19), F.S.
Rulemaking Authority 400.497, 400.506 FS. Implements Florida Statutes § 400.497, 400.506. History—New 2-9-93, Amended 1-27-94, 12-24-00, 8-10-06, 5-4-15.