Florida Regulations 59A-9.031: Clinical Records
Current as of: 2024 | Check for updates
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(1) A permanent individual clinical record shall be kept on each clinic patient. Clinical records shall be complete, accurately documented, and systematically organized to facilitate storage and retrieval.
(a) Clinical records shall contain a printed image of the ultrasound used to determine the period of gestation.
(b) Clinical records shall be kept confidential and secure.
(c) Operative reports signed by the physician performing the second trimester abortion shall be recorded in the clinical record immediately following the procedure or that an operative progress note is entered in the clinical record to provide pertinent information.
(2) Clinical records shall be kept on file for a minimum of five years from the date of the last entry.
Rulemaking Authority 390.012 FS. Law Implemented Florida Statutes § 381.012. History-New 6-13-90, Amended 4-17-91, Formerly 10D-72.031, Amended 9-25-06, 4-5-17.
(b) Clinical records shall be kept confidential and secure.
(c) Operative reports signed by the physician performing the second trimester abortion shall be recorded in the clinical record immediately following the procedure or that an operative progress note is entered in the clinical record to provide pertinent information.
(2) Clinical records shall be kept on file for a minimum of five years from the date of the last entry.
Rulemaking Authority 390.012 FS. Law Implemented Florida Statutes § 381.012. History-New 6-13-90, Amended 4-17-91, Formerly 10D-72.031, Amended 9-25-06, 4-5-17.