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General Records Schedules

General Records Schedule GS4
for
PUBLIC HOSPITALS, HEALTH CARE FACILITIES AND MEDICAL PROVIDERS

New/Revised Items

Effective May 14, 2007, the following three items have been changed to eliminate the following exclusionary language regarding tuberculosis records: ATTN COUNTY HEALTH UNITS: DO NOT USE THIS ITEM FOR TUBERCULOSIS PATIENT MEDICAL RECORDS. CONSULT YOUR AGENCY'S RMLO.

PATIENT MEDICAL RECORD	Item #80
This record series consists of the current and complete medical record for every patient seeking care or service from a healthcare provider or institution, including public providers of dental care and mental health and drug addiction counseling, multiphase clinics, hospitals, county public health units, medical/ dental/ nursing schools, EMS providers, and limited care residential facilities. The medical record shall contain information required for the completion of a birth, death, or stillbirth certificate and may contain the following information: identification data; chief complaint or reason for seeking care; present illness; personal and family medical history; physical examination report; provisional and pre-operative diagnosis; clinical laboratory reports; radiology, diagnostic imaging, and ancillary testing reports; consultation reports; requisitions for laboratory tests; medical and surgical treatment notes and reports; evidence of appropriate informed consent; evidence of medication and dosage administered; a copy of the Florida Emergency Medical Services Report if delivered by ambulance; tissue reports; physician, nurse, and therapist progress notes and reports; principal and secondary diagnoses and procedures when applicable; discharge summary; appropriate social services reports; autopsy findings; individualized treatment plans; clinical assessments of patient's needs; certification of transfer of patient between facilities; routine inquiry form regarding organ donation in the event of death; operative reports and progress notes; postoperative information; referral sources; intake interviews; orientation program documentation; mental status examination and assessments; documentation of seclusion and restraints usage; if applicable a copy the form "Public Baker Act Service Eligibility;" physical, inhalation, speech, and occupational therapy plans, progress notes, and consultations; when applicable, Department of Health or Children and Families' forms for the reporting of child, elder, or domestic violence and trauma reports; anesthesia records; blood donor and transfusion information; organ receipt or tissue transplant records; data on a medical device transplant; bone marrow test reports; dialysis records; diet counseling and restriction notations; interpretations of the EEG, EKG, and fetal heart monitor tracings or if no tracings are reported - the actual tracings are included; infant screening test reports; nuclear medicine reports; x-ray interpretation records; growth charts and allergy history; emergency care rendered prior to arrival at the facility; time police or medical examiner notified; infection notices and follow-up; security notices for violent or unstable patients and accompanying family members; and adverse incident reports. Additional items may be included in the patient medical file on a case by case basis and under the recommendation of a professional or medical standards organization. 59A-3.214, FAC This series may have archival value. RETENTION: a) Record copy. 7 years after last entry b) Duplicates. Retain until obsolete, superseded or administrative value is lost.
PATIENT MEDICAL RECORD: CHILDREN UNDER ONE YEAR OF AGE	Item #130
This record series consists of the current and complete medical record for every patient seeking care or service from a healthcare provider or institution, including public providers of dental care and mental health and drug addiction counseling, multiphase clinics, hospitals, county public health units, medical/dental/nursing schools, EMS providers, and limited care residential facilities. The medical record shall contain information required for the completion of a birth, death, or stillbirth certificate and may contain the following information: identification data; chief complaint or reason for seeking care; present illness; personal and family medical history; physical examination report; provisional and pre-operative diagnosis; clinical laboratory reports; radiology, diagnostic imaging, and ancillary testing reports; consultation reports; requisitions for laboratory tests; medical and surgical treatment notes and reports; evidence of appropriate informed consent; evidence of medication and dosage administered; a copy of the Florida Emergency Medical Services Report if delivered by ambulance; tissue reports; physician, nurse, and therapist progress notes and reports; principal and secondary diagnoses and procedures when applicable; discharge summary; appropriate social services reports; autopsy findings; individualized treatment plans; clinical assessments of patient's needs; certification of transfer of patient between facilities; routine inquiry form regarding organ donation in the event of death; operative reports and progress notes; postoperative information; referral sources; intake interviews; orientation program documentation; mental status examination and assessments; documentation of seclusion and restraints usage; if applicable a copy the form "Public Baker Act Service Eligibility;" physical, inhalation, speech, and occupational therapy plans, progress notes, and consultations; when applicable, Department of Health or Children and Families' forms for the reporting of child, elder, or domestic violence and trauma reports; anesthesia records; blood donor and transfusion information; organ receipt or tissue transplant records; data on a medical device transplant; bone marrow test reports; dialysis records; diet counseling and restriction notations; interpretations of the EEG, EKG, and fetal heart monitor tracings or if no tracings are reported - the actual tracings are included; infant screening test reports; nuclear medicine reports; x-ray interpretation records; growth charts and allergy history; emergency care rendered prior to arrival at the facility; time police or medical examiner notified; infection notices and follow-up; security notices for violent or unstable patients and accompanying family members; and adverse incident reports. Additional items may be included in the patient medical file on a case by case basis and under the recommendation of a professional or medical standards organization. s. 95.11(4)B, FS. This series may have archival value. RETENTION: a) Record copy. Retain until Eighth Birthday. b) Duplicates. Retain until obsolete, superseded or administrative value is lost.
PATIENT MEDICAL RECORD: NURSING HOME MINORS	Item #133
This record series consists of the complete medical record for every patient seeking care or service from a nursing home provider. The medical record shall contain information required for the completion of a birth, death, or stillbirth certificate and may contain the following information: identification data; chief complaint or reason for seeking care; present illness; personal and family medical history; physical examination report; provisional and pre-operative diagnosis; clinical laboratory reports; radiology, diagnostic imaging, and ancillary testing reports; consultation reports; requisitions for laboratory tests; medical and surgical treatment notes and reports; evidence of appropriate informed consent; evidence of medication and dosage administered; a copy of the Florida Emergency Medical Services Report if delivered by ambulance; tissue reports; physician, nurse, and therapist progress notes and reports; principal and secondary diagnoses and procedures when applicable; discharge summary; appropriate social services reports; autopsy findings; individualized treatment plans; clinical assessments of patient's needs; certification of transfer of patient between facilities; routine inquiry form regarding organ donation in the event of death; operative reports and progress notes; postoperative information; referral sources; intake interviews; orientation program ocumentation; mental status examination and assessments; documentation of seclusion and restraints usage; if applicable a copy the form "Public Baker Act Service Eligibility;" physical, inhalation, speech, and occupational therapy plans, progress notes, and consultations; when applicable, Department of Health or Children and Families' forms for the reporting of child, elder, or domestic violence and trauma reports; anesthesia records; blood donor and transfusion information; organ receipt or tissue transplant records; data on a medical device transplant; bone marrow test reports; dialysis records; diet counseling and restriction notations; interpretations of the EEG, EKG, and fetal heart monitor tracings or if no tracings are reported - the actual tracings are included; infant screening test reports; nuclear medicine reports; xray interpretation records; growth charts and allergy history; emergency care rendered prior to arrival at the facility; time police or medical examiner notified; infection notices and follow-up; security notices for violent or unstable patients and accompanying family members; and adverse incident reports. Additional items may be included in the patient medical file on a case by case basis and under the recommendation of a professional or medical standards organization. 59A-4.118, FAC and s. 95.11, FS This series may have archival value. RETENTION: a) Record copy. Retain until 24 years of age or 7 years after last entry, whichever is longer. b) Duplicates. Retain until obsolete, superseded or administrative value is lost.

Effective May 14, 2007, the following item has been changed to eliminate the following exclusionary language regarding tuberculosis records: These films can cover any disease or injury except tuberculosis.

X-RAY FILMS

Item #78

This record series consists of developed x-ray film which may have been interpreted by a radiologist. Interpretations of these films may be found in the Patient Medical Record. Mammograms of returning patients are included in this series. Mammograms of one-time-visitors are located in Item #90, Mammograms. RETENTION: a) Record copy. 7 years. b) Duplicates. Retain until obsolete, superseded or administrative value is lost.