N.J. Admin. Code § 13:34C-4.1

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

Section 13:34C-4.1 - Preparation and maintenance of client records

(a) A licensee or certificate holder shall prepare a permanent client record for each client which accurately reflects the client contact with the licensee whether in an office, hospital, agency or other treatment, evaluation or consultation setting.

(b) A licensee or certificate holder shall make and sign entries in the client record contemporaneously with the services provided. A licensee or certificate holder may dictate an entry for later transcription, provided that the transcription is dated and identified as "preliminary" until the licensee or certificate holder reviews the transcription and finalizes the entry in the client record.

(c) The licensee or certificate holder shall include in the client record material pertinent to the nature and extent of the professional interaction, as applicable:

1. The client name, address, and telephone numbers;

2. The client complaint on intake;

3. Medical history recognized as of potential significance;

4. Substance abuse history;

5. Past and current medications;

6. Bio/psycho/social history;

7. Any finding or interpretation of standardized tests and/or instruments administered;

8. Current functional impairments and rating levels thereof;

9. A diagnostic impression;

10. A treatment plan and recovery maintenance plan focused on the specific needs of the individual client;

11. Contemporaneous and dated progress or session notes specific to the client's participation, including on-going assessment, specific components of treatment, evaluation or consultation;

12. Dates of all treatment, evaluation or consultation sessions;

13. The location of treatment, evaluation or consultation;

14. A prognosis;

15. The client identity on each page;

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

17. The identity of each provider of treatment, evaluation or consultation (and supervisor, if any);

18. If services are rendered by a counselor intern or a certified alcohol and drug counselor, a written disclosure form signed by the client;

19. Records and reports provided by other professionals;

20. Information regarding referrals to other professionals or health care providers;

21. Appropriate consent and disclosure forms required by law;

22. Any other form required by regulation, accreditation or funding agency;

23. Discharge summary and after care plan focused on the specific needs of the individual client; and

24. A record of any treatment, drug, or service offered by the licensee and refused by the patient.

(d) A licensee or certificate holder may make corrections or additions to an existing record provided that each change is clearly identified as such, dated and initialed by the licensee or certificate holder.

(e) The licensee or certificate holder shall establish and maintain a reasonable procedure to protect such records from access by unauthorized persons.

(f) The licensee or certificate holder shall retain the permanent client record for at least seven years from the date of last entry, unless otherwise provided by law. For clients who are minors, a licensee or certificate holder shall retain the records for seven years from the date of last entry or two years past the client's 18th birthday, whichever is later.

(g) The licensee or certificate holder shall establish reasonable procedures for maintaining the confidentiality of client records in the event of the licensee's or certificate holder's relocation, retirement, termination from practice, death, or separation from a group practice, and shall establish reasonable procedures to assure the preservation of client records which shall include at a minimum:

1. Establishment of a procedure by which patients can obtain treatment records or acquiesce in the transfer of those records to another licensee or health care professional who is assuming the responsibilities of that practice;

2. Publication of a notice of the cessation and the established procedure for the retrieval of records in a newspaper of general circulation in the geographic location of the licensee's or certificate holder's practice, at least once each month for the first three months after the cessation; and

3. Making reasonable efforts to directly notify any patient treated during the six months preceding the cessation, providing information concerning the established procedure for retrieval of records.

(h) Subsections (e), (f), and (g) above shall not apply to a licensee or certificate holder employed in an agency setting who does not, by agency policy, have control over client records.

(i) Licensees or certificate holders practicing in a substance abuse treatment facility licensed by the Division of Mental Health and Addiction Services, or in an exempt setting as defined in N.J.A.C. 13:34C-2.6, shall not be required to comply with this section, if the facility's policies and/or procedures regarding preparation and maintenance of client records differ from this section.

N.J. Admin. Code § 13:34C-4.1

Amended by 49 N.J.R. 664(a), effective 4/3/2017