N.J. Admin. Code § 13:38-2.3

Current through Register Vol. 56, No. 24, December 18, 2024

Section 13:38-2.3 - Records of examinations and prescriptions; computerized records

(a) Licensees shall prepare and maintain contemporaneous, legible, permanent professional treatment and billing records made to patients or third-party carriers for professional services. All treatment records, bills and claim forms shall accurately reflect the treatment of services rendered. Treatment and billing records shall be maintained for a period of not less than seven years from the date of the most recent entry.

(b) To the extent applicable, professional treatment records shall contain, in addition those findings required by the minimum examination as set forth in N.J.A.C. 13:38-2.1:

1. The dates of all patient visits, examinations, and treatments;

2. The patient complaint or reason for visit;

3. The patient history;

4. The findings of the examination;

5. Progress notes;

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

7. Diagnosis or impression;

8. Complete eyeglass, contact lens, or pharmaceutical prescriptions;

9. The treatment or plan initiated, including specific dosages, quantities and strengths of medications, including the number of refills, if prescribed, administered or dispensed, and recommended follow-up;

10. The identity of the optometrist providing treatment and the name of the person dispensing eyeglasses, contact lenses, or issuing pharmaceutical prescriptions to the patient;

11. Documentation when, in the reasonable exercise of the optometrist's judgment, the communication of examination results is necessary and action needs to be taken but reasonable efforts made by the optometrist responsible for communication have been unsuccessful; and

12. Documentation concerning the decision and justification when, after the required evaluation of a patient for the specifically advertised brand and type of contact lens which attracted or induced the patient to seek such goods, the patient is fitted with another brand or type of contact lens.

(c) Corrections, but no deletions or additions, may be made to an existing record, provided that each entry is clearly identified as such and initialed and dated by the licensee.

(d) Treatment records may be prepared and maintained on a personal or other computer but shall be in compliance with the following criteria:

1. The record shall contain no less than two independent forms of identification, such as patient name and record number;

2. An entry in a patient's treatment record shall be made by the optometrist contemporaneously with the optometric service and shall contain all of the information required in (b) above, and the full printed name of the optometrist providing the care. The system and/or software shall be set up in such a way that all data and findings must be manually entered and are not entered by default;

3. The optometrist shall finalize or "sign" the entry by means of a confidential personal code ("CPC") and include the date of the "signing." In those practices with multiple licensees, each optometrist shall have his or her own CPC;

4. The optometrist may dictate a dated entry for later transcription. The transcription shall be identified as "preliminary" until reviewed and finalized as provided in 3, above;

5. The system used to record the treatment record shall provide an automatic dating of the entry and prepare an automatic back-up file. No other data or findings may be entered automatically by the system. Any additional data or findings shall be entered manually each time a patient's treatment record is updated;

6. The system shall not allow an entry to be modified in any manner after it is "signed" by means of the CPC. A new entry shall be required to modify a preexisting entry and signed again by means of the CPC;

7. The system shall have the capability to print on demand a hard copy of all current and historical data contained in each patient record file;

8. The optometrist shall maintain the safety and security of back-up data and hard copies maintained off premises; and

9. The optometrist shall provide to the Board upon request any back-up data and/or hard copies maintained off premises on any requested patient records, together with the following information:

i. The name of the computer operating system and patient record management software package containing the requested patient record files and instructions on using such system;

ii. Current passwords necessary to access the requested patient record files;

iii. Previous passwords if required to access the requested patient record files; and

iv. The name of the contact person(s) who provides technical support for the licensee's computer operating system and patient record management software package.

N.J. Admin. Code § 13:38-2.3

Amended by R.1985 d.60, effective 2/19/1985.
See: 16 N.J.R. 3289(a), 17 N.J.R. 467(a).
(c) added.
Amended by R.1989 d.252, effective 5/15/1989.
See: 20 N.J.R. 236(b), 21 N.J.R. 1366(b).
Added new (e), clarifying procedure regarding an optometrist's responsibility for patient evaluation for a specifically advertised brand of contact lenses.
Amended by R.1993 d.357, effective 7/19/1993.
See: 24 N.J.R. 4237(a), 25 N.J.R. 3232(a).
Petition for Rulemaking.
See: 26 N.J.R. 4707(c).
Amended by R.1995 d.524, effective 9/18/1995.
See: 27 N.J.R. 2092(a), 27 N.J.R. 3617(a).
Petition for Rulemaking.
See: 30 N.J.R. 2958(b), 30 N.J.R. 3109(a).
Amended by R.2006 d.126, effective 4/3/2006.
See: 37 N.J.R. 3780(a), 38 N.J.R. 1574(b).
In (a), added "legible,"; in (b)8, made grammatical changes and added ", or pharmaceutical"; rewrote (b)10; in (c), substituted "Corrections, but no deletions or additions," for "Corrections or additions, but no deletions," and "entry" for "change"; deleted (d)10.
Amended by R.2012 d.077, effective 4/16/2012.
See: 43 N.J.R. 822(a), 44 N.J.R. 1272(a).
In (a), inserted "and maintain", inserted "and billing" twice, and deleted "and shall also maintain records relating to billings" preceding "made".