N.J. Admin. Code § 13:34-8.1

Current through Register Vol. 56, No. 21, November 4, 2024

Section 13:34-8.1 - Preparation and maintenance of client records

(a) A licensee shall prepare and maintain separately for each client a contemporaneous, permanent client record that accurately reflects the client contact with the licensee whether in an office, hospital or other treatment, evaluation or consultation setting.

(b) The licensee shall include at least the following information in the client record:

1. The client name (on each page of the record), address, and telephone number;

2. The location and dates of all treatment, evaluation, or consultation settings;

3. The identity of each provider of treatment, evaluation, or consultation, and the supervisor, if any;

4. The presenting situation;

5. Significant medical and psychosocial history;

6. Past and current medication, when appropriate;

7. An assessment of current marriage and family lifestyle;

8. A diagnostic assessment and prognosis;

9. A treatment plan;

10. Progress notes for each session;

i. A therapist may dictate progress and session notes for later transcription provided the transcription is dated and identified as preliminary pending the therapist's final review and approval.

11. Information regarding referrals to other professionals and reports and records provided by other professionals;

12. Fees charged and paid unless a separate financial record is kept; and

13. A summary of the termination of services, in accordance with N.J.A.C. 13:34-6.3, including, but not limited to: the reason for termination of service, a summary of the information provided and topics discussed during the process of terminating services, the review of the treatment plan, follow-up and transitional services, communication with client about termination of services, and, as applicable, communication with other mental health professionals associated with the coordination of treatment.

(c) The licensee shall periodically review and update the treatment plan.

(d) The licensee shall retain the permanent client record for at least seven years from the date of the last entry, unless otherwise provided by law, or in the case of a minor, the licensee shall retain the record until the minor reaches the age of 25.

1. This requirement shall not apply to a licensee employed in an agency setting if the agency's policy does not permit a licensee to control the retention of records.

N.J. Admin. Code § 13:34-8.1

Amended by 49 N.J.R. 655(a), effective 4/3/2017