N.J. Admin. Code § 13:35-9.16

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

Section 13:35-9.16 - Preparation of patient records; computerized records; access to or release of information; confidentiality, transfer or disposal of records

(a) The following words and terms, as used in this section, shall have the following meanings unless the context clearly indicates otherwise:

1. "Authorized representative" means a person who has been designated by the patient or a court to exercise rights under this section. An authorized representative may be the patient's attorney or an employee of an insurance carrier with whom the patient has a contract which provides that the carrier be given access to records to assess a claim for monetary benefits or reimbursement. If the patient is a minor, a parent or guardian who has custody (whether sole or joint) shall be deemed to be an authorized representative.

2. "Patient" means any person who is the recipient of acupuncture.

(b) Acupuncturists shall prepare contemporaneous, permanent professional treatment records. Acupuncturists shall also maintain records relating to billings made to patients and third-party carriers for professional services. All treatment records, bills, and claim forms shall accurately reflect the treatment or services rendered. Treatment records shall be maintained for a period of seven years from the date of the most recent entry.

1. To the extent applicable, professional treatment records shall reflect:

i. The dates of all treatments;

ii. The patient complaint;

iii. The history;

iv. Progress notes;

v. Any orders for tests or consultations and the results thereof;

vi. Documentation indicating that informed consent was given by the patient;

vii. Findings from examinations;

viii. If a physician has referred a patient for acupuncture, an indication that a referral or diagnosis was made by a physician, including the name of the physician; and

ix. Documentation of any recommendations made to a patient for the use of meditation or products that facilitate health.

2. Corrections and/or additions may be made to an existing record, provided that each change is clearly identified as such, dated and initialed by the licensee;

3. A patient record that is prepared and maintained on a personal or other computer shall be prepared and maintained as follows:

i. The patient record shall contain at least two forms of identification, for example, name and record number or any other specific identifying information;

ii. The entry made by the acupuncturist shall be made contemporaneously with the treatment and shall contain the date of service, date of entry, and full printed name of the treatment provider. The acupuncturist shall finalize or "sign" the entry by means of a confidential personal code ("CPC") and include date of the "signing";

iii. The acupuncturist may dictate a dated entry for later transcription. The transcription shall be dated and identified as "preliminary" until reviewed, finalized and dated by the acupuncturist as provided in (b)3ii above;

iv. The computer system shall contain an internal permanently activated date and time recordation for all entries, and shall automatically prepare a back-up copy of the file;

v. The computer system shall be designed in such manner that after "signing" by means of the CPC, the existing entry cannot be changed in any manner. Notwithstanding the permanent status of a prior entry, a new entry may be made at any time and may indicate correction to a prior entry;

vi. Where more than one acupuncturist is authorized to make entries into the computer file of any professional treatment record, the acupuncturist responsible for the acupuncture practice shall assure that each such person obtains a CPC and uses the file program in the same manner; and

vii. A copy of each day's entry, identified as preliminary or final as applicable, shall be made available to a physician responsible for the patient's care, to a representative of the Board, the Attorney General or the Division of Consumer Affairs no later than 10 days after a request for the record, or to a patient within 30 days of the request or promptly in the event of emergency.

(c) Acupuncturists shall provide access to professional treatment records to a patient or an authorized representative in accordance with the following:

1. No later than 30 days from receipt of a request from a patient or an authorized representative, the acupuncturist shall provide a copy of the professional treatment record, and/or billing records as may be requested. The record shall include all pertinent objective data including test results, as applicable, and subjective information.

2. Unless otherwise required by law, an acupuncturist may, if a patient requests, provide a summary of the record in lieu of providing a photocopy of the actual record, so long as that summary adequately reflects the patient's history and treatment. An acupuncturist may charge a reasonable fee for the preparation of a summary, which has been provided in lieu of the actual record, which shall not exceed the cost allowed by (c)3 below for that specific record.

3. Acupuncturists may require that a record request be in writing and may charge a fee for the reproduction of records, which shall be no greater than $ 1.00 per page or $ 100.00 for the entire record, whichever is less. If the record requested is less than 10 pages, the acupuncturist may charge up to $ 10.00 to cover postage and the miscellaneous costs associated with retrieval of the record. If the acupuncturist provides a summary in lieu of the actual record, the charge for the summary shall not exceed the cost that would be charged for the actual record.

4. If the patient or a subsequent treating health care professional is unable to read the treatment record, either because it is illegible or prepared in a language other than English, the acupuncturist shall provide a transcription at no cost to the patient.

5. The acupuncturist shall not refuse to provide a professional treatment record on the grounds that the patient owes the licensee an unpaid balance if the record is needed by another health care professional for the purpose of rendering care.

(d) Acupuncturists shall maintain the confidentiality of professional treatment records, except that:

1. The acupuncturist shall release patient records as directed by a subpoena issued by the Board or the Office of the Attorney General, or by a demand for statement in writing under oath from the Board or the Office of the Attorney General, pursuant to 45:1-18. Such records shall be originals, unless otherwise specified, and shall be unedited, with full patient names. To the extent that the record is illegible, the acupuncturist, upon request, shall provide a typed transcription of the record. If the record is in a language other than English, the acupuncturist shall also provide a translation.

2. The acupuncturist shall release information as required by law or regulation.

3. The acupuncturist, in the exercise of professional judgment and in the best interests of the patient (even absent the patient's request), may release pertinent information about the patient's treatment to another licensed health care professional who is providing or has been asked to provide treatment to the patient, or whose expertise may assist the acupuncturist in his or her rendition of professional services.

(e) Where the patient has requested the release of a professional treatment record or a portion thereof to a specified individual or entity, in order to protect the confidentiality of the records, the acupuncturist shall:

1. Secure and maintain a current written authorization, bearing the signature of the patient or an authorized representative;

2. Assure that the scope of the release is consistent with the request; and

3. Forward the records to the attention of the specific individual identified or mark the material "Confidential."

(f) If an acupuncturist ceases to engage in practice or it is anticipated that he or she will remain out of practice for more than three months, the acupuncturist or designee shall:

1. Establish a procedure by which patients can obtain a copy of the treatment records or acquiesce in the transfer of those records to another licensee who is assuming responsibilities of the practice. However, an acupuncturist shall not charge a patient, pursuant to (c)3 above, for a copy of the records, when the records will be used for purposes of continuing treatment or care.

2. Publish 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 acupuncturist's practice, at least once each month for the first three months after the cessation; and

3. Make 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.

N.J. Admin. Code § 13:35-9.16

Repeal and New Rule, R.1999 d.356, effective 10/18/1999.
See: 31 N.J.R. 1742(a), 31 N.J.R. 3117(a).
Section was "Patient records".
Amended by R.2005 d.120, effective 4/18/2005.
See: 36 N.J.R. 4633(a), 37 N.J.R. 1203(a).
Substituted "certificate holder" for "licensee" throughout.
Recodified from N.J.A.C. 13:35-9.11 and amended by R.2010 d.101, effective 6/21/2010.
See: 41 N.J.R. 2617(a), 42 N.J.R. 1216(a).
In (a)2, substituted "acupuncture" for "a professional service rendered by a certificate holder for purposes of treatment"; in (b)1iv, deleted "and" from the end; in (b)1v, substituted a semicolon for period at the end; added (b)1vi through (b)1viii; in the introductory paragraph of (b)3, substituted "that" for "which"; in (b)3vi, inserted "and" at the end; in (b)3vii, deleted "of Acupuncture Examiners" following "Board", substituted "a request for the record" for "notice", and deleted a comma following the last occurrence of "request"; deleted (b)3viii; in (c)2, substituted ", if a patient requests," for "elect to" and inserted a comma following the last occurrence of "summary"; in (c)3, substituted "Acupuncturists" for "Acupuncturist" and "acupuncturist provides" for certificate holder elects to provide", and inserted the second sentence; and in (d)1, deleted "of Acupuncture Examiners" following the first occurrence of "Board", and inserted "from the Board or the Office of the Attorney General". Former N.J.A.C. 13:35-9.16, Training required of a physician or dentist, repealed.
Amended by R.2014 d.066, effective 4/21/2014.
See: 45 N.J.R. 729(a), 45 N.J.R. 1589(a), 46 N.J.R. 695(b).
In the introductory paragraph of (b), inserted a comma following "bills"; in (b)1vii, deleted "and" from the end; rewrote (b)1viii; added (b)1ix; in (b)2, (c)5, and (f)1, substituted "licensee" for "certificate holder"; and in (f)1, inserted a comma following the second occurrence of "records".