Florida Administrative Code › 59 - AGENCY FOR HEALTH CARE ADMINISTRATION › 59A - Health Facility and Agency Licensing › Chapter 59A-23 - WORKERS COMPENSATION MANAGED CARE ARRANGEMENTS › Section 59A-23.005 - Medical Records and Case Files

Current through Reg. 50, No. 138; July 16, 2024
(1) The
				insurer or delegated entity shall implement a system for managing electronic
				and paper medical information necessary to promote the prompt delivery of
				medical services in order to return the injured employee to work as soon as
				medically feasible.
(2) Provider
				Medical Records. The insurer or delegated entity shall maintain or assure that
				its providers maintain a medical records system, which is consistent with
				professional standards, pursuant to Section
				456.057, F.S. The insurer or
				delegated entity shall develop and implement policies and procedures that:
(a) Permit prompt retrieval of legible and
				timely information, which is accurately documented and readily available if
				requested by a health care practitioner with written authorization and consent
				from the patient when required by statute;
(b) Protect the confidentiality and security
				of paper and electronic patient records including:
1. Transfer, storage, and faxing of records;
				and,
2. Handling of records
				containing information on HIV, substance abuse, and mental health, in
				accordance with statutory requirements;
(c) Provide for the training and education of
				administrative staff and providers on medical record documentation, policies
				and procedures, storage and confidentiality of patient records;
(d) Document in the medical record a summary,
				related to work injury or illness, of significant procedures, past and current
				diagnoses or problems and allergies and adverse reactions to current
				medications;
(e) Identify the
				patient as follows:
1. Name;
2. Social Security, alien identification
				number, or other identification number;
3. Date of Birth; Employer; home and work
				telephone numbers;
4. Sex; and,
5. Date of work injury or
				illness.
(f) Indicate in
				the medical record for each visit the following information:
1. Date;
2. Chief complaint, unresolved problems or
				complaints from prior interventions and purpose of visit;
3. Objective findings of
				practitioner;
4. Diagnosis or
				medical impression;
5. Studies
				ordered, for example: lab, x-ray, EKG, and referral reports;
6. Therapies administered and
				prescribed;
7. Name and profession
				of practitioner rendering services, for example: M.D., D.O., D.C., D.P.M.,
				R.N., O.D., etc., including signature or initials of practitioner;
8. Disposition, recommendations,
				instructions, and education to the patient. Evidence of whether there was
				follow-up and the specific time of return is noted in weeks, months or as
				needed;
9. Outcome of
				services;
10. Work status, release
				for return to work, work restrictions; and,
11. Evidence of coordination of care and any
				injured employee non-compliance with treatment.
(g) Require the insurer or delegated entity
				to request written consent of patients for release of medical records that are
				subject to the limitations in Sections
				381.004 and
				456.057, F.S., and for obtaining
				and sharing all documents and medical records from providers necessary to carry
				out the provisions of Section
				440.134, F.S.; and,
(h) Address transfer and retrieval of
				records, and provision of copies when requested by the patient, designated
				representative, or the Agency pursuant to Section
				440.13(4)(c),
				F.S. The insurer or delegated entity shall communicate its policy to providers
				via provider educational materials.