N.J. Admin. Code § 13:39A-3.2

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

Section 13:39A-3.2 - Use of personal or other computer to prepare patient records

(a) A licensee who prepares a patient record maintained solely on a personal or other computer shall use a write-protected program which:

1. Contains an internal permanently activated date and time recordation for all entries;

2. Automatically prepares a back-up copy of the file; and

3. Is designed in such manner that, after the licensee "signs" by means of a confidential personal code ("CPC"), the entry cannot be changed in any manner.

(b) The licensee shall include in the patient record at least two forms of identification; for example, name and record number of the patient or any other specific identifying information.

(c) The licensee shall finalize or "sign" the entry by means of a CPC. Where more than one individual is authorized to make entries into the computer file of any patient record, the licensee responsible for the entity shall assure that each such person obtains a CPC and uses the program in the same manner.

(d) The licensee shall generate a hard copy of the complete patient record, or a portion thereof, upon request.

(e) Notwithstanding N.J.A.C. 13:39A-3.1(c)1, a licensee who maintains a patient record solely on a personal or other computer shall not be required to include his or her name and license number on every page of a patient record; however, the name and license number shall appear at least once on the patient record.

(f) A licensee who generates a hard copy of a patient record pursuant to (d) above shall ensure that the hard copy is paginated with each page being a specified number of the total number of pages in the record.

N.J. Admin. Code § 13:39A-3.2

Amended by 47 N.J.R. 3048(a), effective 12/7/2015