(1) A medical record must be developed at the time of admission, must be maintained for each child, signed by authorized personnel and contain at least the following:
    (a) A medical plan of treatment and a nursing protocol of care.
    (b) All details of the referral, admission, correspondence and papers concerning the child.
    (c) Physician orders.
    (d) Flow chart of medications and treatments administered.
    (e) Concise, accurate information and initialed case notes reflecting progress toward achievement of care goals or reasons for lack of progress.
    (f) Documentation of nutritional management and special diets, as appropriate.
    (g) Documentation of physical, occupational, speech and other special therapies.
    (2) The individualized nursing care protocol must be developed within ten (10) working days of admission. The protocol must be reviewed monthly and revised quarterly, and include any recommendations and revisions to the plan based on consultation with other professionals involved in the child’s care.
    (3) Medical history, including allergies and special precautions.
    (4) Immunization record.
    (5) A discharge order written by the primary physician will be documented and entered in the child’s record. A discharge summary, which includes the reason for discharge, will also be included.
Rulemaking Authority Florida Statutes § 400.914(1). Law Implemented 400.914(1)(h) FS. History-New 3-8-89, Formerly 10D-102.014, Amended 6-22-06.