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Fla. Admin. Code R. 59A-8.022 - Clinical Records

FloridaregulationFlorida Agency for Health Care Administration (AHCA)· effective 2013-07-11

What this rule requires your agency to do

  • 1The agency must retain clinical records as required by section 400.491, F.S., in a format (hard paper copy, microfilm, computer disks or tapes) that is retrievable and available during inspections. (Fla. Admin. Code R. 59A-8.022; s. 400.491, F.S.)(Fla. Admin. Code R. 59A-8.022; s. 400.491, F.S.)
  • 2The agency must maintain a clinical record for each patient receiving nursing or therapy services that includes source of referral, physician orders, patient needs assessments, care plans with updates, signed clinical and service notes, supervision reports, case conference reports, physician communications, and a termination summary. (Fla. Admin. Code R. 59A-8.022)(Fla. Admin. Code R. 59A-8.022)
  • 3The agency must not disclose any information from the patient's file without the written consent of the patient or the patient's guardian. (Fla. Admin. Code R. 59A-8.022)(Fla. Admin. Code R. 59A-8.022)
  • 4The agency must document in the termination summary the date of the first and last visit, the reason for termination of service, and the patient's condition at discharge. (Fla. Admin. Code R. 59A-8.022)(Fla. Admin. Code R. 59A-8.022)
  • 5The agency must ensure clinical and service notes are signed by the staff providing the service, permitting facsimile signatures for care plans and orders and electronic signatures for computer-based records only where a unique identifier authenticates the signer and safeguards prevent unauthorized access. (Fla. Admin. Code R. 59A-8.022)(Fla. Admin. Code R. 59A-8.022)

Applies to: home health / home care agencies providing nursing or therapy services to patients

Rule 59A-8.022 requires Florida-licensed home health agencies to maintain a clinical record for each patient receiving nursing or therapy services, specifies the required contents, mandates confidentiality, and requires records to be retained per s. 400.491, F.S., in a retrievable format available during inspection.

Regulatory information, not legal advice — always confirm against the cited official source. Verification reduces error; it does not certify compliance.