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Florida Administrative Code § 59A-5.012
Link to the law
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Current as of June 2015
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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:
Current as of June 2015
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