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... Are you a Curi member? The full content of this resource is available only to Curi members. Contact us if you are a member but do not have an account yet, or to learn more about becoming a Curi member. Sign in to see full post News & Knowledge READ NEXT September 11, 2020February 24, 2023Electronic Communication & Social Media | Medical Records | Patient Management Florida Handbook: Electronic Communication and Documentation DOES THE PRIVACY RULE PERMIT ME TO COMMUNICATE WITH PATIENTS USING ELECTRONIC (EMAIL)? The HIPAA Privacy Rule allows covered entities to communicate electronically, provided they use… Read more September 11, 2020February 24, 2023Medical Records Florida Handbook: Release of Medical Information: Special Issues Our office treats a number of workers’ compensation patients. When releasing medical information, are the rules different for these patients? Records of workers’ compensation patients are… Read more September 11, 2020February 24, 2023Medical Records Florida Handbook: Subpoenas WE HAVE RECEIVED A SUBPOENA FOR MEDICAL RECORDS. DO WE HAVE TO COMPLY? Record requests from attorneys and other legal representatives can be confusing to medical… Read more