Florida Handbook: Documentation

WHAT ITEMS SHOULD BE PRESENT IN A PATIENT’S MEDICAL RECORD? The importance of careful and accurate documentation in the medical record cannot be overstated. In a malpractice lawsuit, the medical record is an essential element of your defense, and its contents may affect the outcome. Clear and comprehensive documentation also enables a physician to plan and evaluate treatments and to communicate with other providers. Guarding the integrity of office practice medical records is the responsibility of the physician(s). Policies and procedures should govern how and when documentation occurs in your office. Florida law has specific requirements for what is contained within a patient’s medical record. First and foremost, the patient’s medical records shall be maintained in English, in a legible manner, and with sufficient detail to clearly demonstrate why a course of treatment was undertaken. Florida Board of Medicine (MDs): The Florida Board of Medicine promulgated Rule 64B8-9.0...