N.J. Admin. Code § 13:44C-8.1

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

Section 13:44C-8.1 - Recordkeeping

(a) Licensees shall maintain written, contemporaneous patient records, which include:

1. Findings upon initial examination including the patient's significant past history and results of appropriate tests and measures;

2. A written plan of care indicating the goals of the treatment program, the type of treatment, and the frequency and expected duration of treatment for audiology and/or speech-language pathology services;

3. Dated documentation of each treatment rendered, which contains the licensee's full name and license number;

4. Dated and signed progress notes;

5. Documentation of any changes in the treatment program;

6. Documentation of any contact with other health professionals relative to the patient's care;

7. A discharge summary which includes the reason for discharge and the outcome of services rendered; and

8. Any pertinent legal document such as patient release forms or charge access sheets.

(b) Treatment records for patients shall be maintained for at least seven years from date of the most recent entry. Records for minors shall be kept for seven years from the date of the most recent entry or until the patient turns 20 years old, whichever is longer.

(c) Licensees shall provide access to patient treatment records to a patient or person whom the patient has designated to receive records in accordance with the following:

1. No later than 30 days from receipt of a request from a patient or a person whom the patient has designated to receive records, the licensee 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. The licensee 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 licensee may charge up to $ 10.00 to cover postage and the costs associated with retrieval of the record;

3. If the patient or a subsequent treating health care professional is unable to read the patient record, either because it is illegible or prepared in a language other than English, the licensee shall, upon request, provide an English transcription at no cost to the patient; and

4. The licensee shall not refuse to provide a patient record on the grounds that the patient owes the licensee an unpaid balance.

(d) All licensees shall prepare, within 30 days of a written request from a patient or any person whom the patient has designated to receive such, a written report summarizing the information set forth in (a) above.

N.J. Admin. Code § 13:44C-8.1

Correction: Deleted audiological from (a)2.
See: 20 N.J.R. 2069(b).
Amended by R.1993 d.383, effective 8/2/1993.
See: 25 N.J.R. 1668(a), 25 N.J.R. 3504(b).
Repeal and New Rule, R.2004 d.23, effective 1/20/2004.
See: 35 N.J.R. 3273(a), 36 N.J.R. 527(a).
Section was "Unprofessional conduct".
Amended by R.2005 d.7, effective 1/3/2005.
See: 36 N.J.R. 1727(a), 37 N.J.R. 82(a).
Rewrote (c).
Amended by R.2005 d.339, effective 10/3/2005.
See: 37 N.J.R. 1164(a), 37 N.J.R. 3836(b).
In (c), added the last sentence in 2 and deleted "if the record is needed by another health care professional for the purpose of rendering care" in 4.
Amended by R.2009 d.87, effective 3/16/2009.
See: 40 N.J.R. 5175(a), 41 N.J.R. 1259(a).
In the introductory paragraph of (a), inserted a comma following "records"; and rewrote (a)3.