N.J. Admin. Code § 10A:31-13.28

Current through Register Vol. 56, No. 23, December 2, 2024

Section 10A:31-13.28 - Medical records

(a) A medical record shall be maintained for each inmate to accurately document all healthcare services in one or both of the following:

1. "Electronic medical record" (EMR), which is a healthcare record of an inmate in an electronic format that contains recorded information concerning the medical, dental and mental health history and related health activities of the inmate; and/or

2. "Medical reference file" (MRF), which is a paper, written or printed record that contains information concerning the medical, dental and mental health history and related health activities of an inmate.

(b) The EMR and/or MRF shall contain the following:

1. Completed medical screening forms;

2. First appraisal data collection forms;

3. All findings, diagnoses, treatments, dispositions, prescriptions and administrations of medication;

4. Notes concerning health, medical instructions, or health education provided to the inmate; and

5. Notation of place, date and time of medical encounters and discharges from medical treatment.

(c) The method of recording entries in the EMR and/or MRF and the form and format of the record shall be approved by the physician who is responsible for medical services.

(d) Access to the EMR and/or MRF is controlled by the physician who is responsible for medical services. The physician/patient privilege shall apply to the EMR and MRF (see N.J.A.C. 10A:31-6). An inmate may obtain a copy of his or her medical records in accordance with 13:35-6.5 as amended and supplemented. Additionally, an inmate may request an amendment or correction of his or her medical record in writing to the physician or designee who is responsible in accordance with internal management procedures. The inmate shall be notified as soon as possible within 60 calendar days of the receipt of the request to amend or correct the medical record that:

1. The request has been granted and the amendment or correction has been made and the amended or corrected section of the record will be provided to the inmate at no cost to the inmate;

2. The request has been denied along with a written statement of the reasons for the denial and information regarding appeal procedures; or

3. An extension has been deemed necessary in order to research or obtain additional information relative to the request. In this case, the written notification shall include reasons for the extension and the reasonable time period within which a response will be provided.

(e) The EMR and/or MRF shall be kept separate from the inmate's classification record.

(f) A medical summary sheet shall accompany an inmate who is being transferred from one facility to another.

N.J. Admin. Code § 10A:31-13.28

Recodified from 10A:31-13.26 by R.1991 d.190, effective 4/15/1991 (operative April 22, 1991).
See: 23 N.J.R. 15(a), 23 N.J.R. 1128(b).
Recodified from N.J.A.C. 10A:31-13.27 and amended by R.2000 d.332, effective 8/7/2000.
See: 32 N.J.R. 1894(a), 32 N.J.R. 2945(a).
Added (e). Former N.J.A.C. 10A:31-13.28, Informed consent for treatment, recodified to N.J.A.C. 10A:31-13.29.
Amended by R.2006 d.59, effective 2/6/2006.
See: 37 N.J.R. 3201(a), 38 N.J.R. 995(a).
Rewrote the section.
Amended by R.2008 d.48, effective 4/7/2008.
See: 39 N.J.R. 2583(c), 40 N.J.R. 1869(a).
In the introductory paragraph of (d), added the third through fifth sentences; and added (d)1 through (d)3.