The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Florida Physical Therapy Medical Records
What are the physical therapist’s documentation responsibilities?
Keep written medical records justifying the course of treatment of the patient, including, but not limited to, initial physical therapy assessment, plan of treatment, treatment notes, progress notes, examination results, test results, and discharge summary.
How much can I charge a patient for copies of their records?
Any person required to release copies of reports or patient medical records, or make reports or records available for digital scanning, may condition such release upon payment by the requesting party of no more than the reasonable costs of reproducing the records, including reasonable staff time.
Reasonable costs of reproducing copies of written or typed documents or reports shall not be more than the following:
Reasonable costs of reproducing x-rays and such other kinds of records shall be the actual costs. “Actual costs” means the cost of the material and supplies used to duplicate the record and the labor and overhead costs associated with the duplication.
Medical records of PTs relocating or terminating their practice
Medical Records of Deceased, Relocating, or Terminating Practice
Licensees shall retain medical records as long as needed not only to serve and protect clients/patients, but also to protect themselves against adverse actions.
Licensees Relocating or Terminating practice
Each licensee engaged in practice, who maintains the responsibility for client/patient medical records, shall, when terminating or relocating the practice, notify each client/patient of such termination or relocation.
Such notification shall consist of at a minimum, causing to be published, in the newspaper of greatest general circulation in each county in which the licensee practices or practiced, a notice which shall contain the date of termination or relocation and an address at which medical records may be obtained. Such notice shall be published no less than four (4) times over a period of at least four (4) weeks.
The licensee shall place in a conspicuous location in or on the facade of the licensee’s office, a sign, announcing the termination or relocation of the practice. The sign shall be placed at least thirty (30) days prior to the termination or relocation and shall remain until the date of termination or relocation. Both the notice and the sign shall advise the clients/patients of their opportunity to transfer or receive their medical records.
Each such licensee shall ensure that client/patient records are maintained and may be obtained by the client/patient for a minimum of two (2) years after the termination or relocation of practice.
Deceased Physical Therapists or Physical Therapist Assistants
Designate a Party to Maintain Records
Each licensee engaged in practice, who maintains the responsibility for client/patient medical records, shall ensure that the executor, administrator, personal representative or survivor of such licensee shall arrange to maintain those medical records in existence upon the death of the licensee for a period of at least two (2) years from the date of the death of the licensee.
Within one (1) month from the date of death of the licensee, the executor, administrator, personal representative or survivor shall cause to be published in the newspaper of greatest general circulation in the county where the licensee practiced, a notice indicating to the clients/patients of the deceased licensee that the licensee’s medical records are available to the clients/patients or their duly constituted representative from a specific person at a certain location.
At the conclusion of a 22-month period of time from the date of death of the licensee or thereafter, the executor, administrator, personal representative or survivor shall cause to be published once during each week for four (4) consecutive weeks, in the newspaper of greatest general circulation in the county where the licensee practiced, a notice indicating to the clients/patients of the deceased licensee that client/patient records will be disposed of or destroyed one (1) month or later from the last day of the fourth week of publication of notice.
All client/patient records shall be disposed of in a manner that will secure the permanent confidentiality of records.
Fla. Admin. Code § 64B17-6.005