N.J. Admin. Code § 13:44E-2.2

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

Section 13:44E-2.2 - Patient records

(a) A contemporaneous, permanent patient record shall be prepared and maintained by a licensee, which may include information collected by licensed chiropractic assistants, for each person seeking chiropractic services, regardless of whether any care is actually rendered or whether any fee is charged. Licensees also shall maintain records relating to billings made to patients and third party carriers for professional services. All patient records, bills, and claim forms shall accurately reflect the care or services rendered. Such records shall include, as a minimum:

1. The name, address, and date of birth of the patient and, if a minor, the name of the parent or guardian;

2. The patient complaint/reason for visit;

3. A pertinent case history;

4. Findings on appropriate examination;

5. Diagnosis/analysis;

6. A care plan;

7. Any orders for tests or consultations including the clinical indications and the results thereof;

8. The dates of each patient visit;

9. A description of care or services rendered at each visit together with the name of the licensee or other person rendering the care;

10. Notation of significant changes in patient's condition and/or significant changes in care plan;

11. Periodic notation of patient status regardless of whether significant changes have occurred; and

12. An itemized statement of the amount billed and received on patient's account.

(b) Patient records, including all radiographs and other diagnostic findings, shall be maintained for at least seven years from the date of the last entry. In the case of a minor child, records shall be kept for seven years from the date of the last entry or seven years from the date of majority, whichever is later.

(c) All radiographs shall be labeled, as a minimum, with the following identifying information:

1. The name of patient;

2. The date of radiograph;

3. The age of patient and/or date of birth;

4. The name of facility; and

5. Right or left identity.

(d) Licensees shall provide access to patient records to the patient or the patient's authorized representative in accordance with the following:

1. Upon receipt of a written request from a patient or an authorized representative and within 30 days thereof, legible copies of the patient record including, if requested, copies of radiographs, shall be furnished to the patient or an authorized representative or another designated health care provider. To the extent that the record is illegible or prepared in a language other than English, the licensee shall provide a typed transcription and/or translation at no cost to the patient.

2. Except where the complete record is required by applicable law, the licensee may elect to provide a summary of the record, as long as that summary accurately reflects the patient's history and care, where the written request comes from an insurance carrier or its agent 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.

3. A licensee shall provide copies of records in a timely manner to a patient or another designated health care provider where the patient's continued care is contingent upon their receipt. The licensee shall not refuse to provide a patient 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.

4. A licensee may refuse to release a record to a patient if, in the exercise of professional judgment, a licensee has reason to believe that the patient may be harmed by release of the subjective information contained in the patient record or a summary thereof. The record or the summary, with an accompanying notice setting forth the reasons for the original refusal, shall nevertheless be provided upon request of and directly to:

i. The patient's attorney;

ii. Another licensed health care professional; or

iii. The patient's health insurance carrier.

5. The licensee may charge a reasonable fee for the reproduction of records, which shall be no greater than an amount reasonably calculated to recoup the cost of copying or transcription.

(e) Licensees shall maintain the confidentiality of patient records, except that:

2. The licensee, 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 care to another licensed health care professional who is providing or who has been asked to provide care to the patient, or whose expertise may assist the licensee in his or her rendition of professional services.

(f) Where a third party or entity has requested examination or an evaluation of a person for a purpose unrelated to care by the examiner and where a report of the examination is to be supplied to the third party, the licensee rendering those services shall prepare appropriate records and maintain their confidentiality, except to the extent provided by this section. The licensee's report to the third party relating to the patient shall be made part of the record. The licensee shall:

1. Assure that the scope of the report is consistent with the request, to avoid the unnecessary disclosure of diagnoses or personal information which is not pertinent;

2. Forward the report to the individual entity making the request and in accordance with the terms of the patient's authorization; if no specific individual is identified, the report should be marked "Confidential"; and

3. Should the examination disclose abnormalities or conditions not known to the patient, the licensee shall advise the patient to consult another health care professional for treatment.

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

1. Establish a procedure by which patients can obtain patient 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. If the practice is unattended by another licensee, 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 licensee's practice, at least once each month for the first three months after the cessation;

3. File a notice of the established procedure for the retrieval of records with the Board of Chiropractic Examiners; and

4. Make reasonable efforts to directly notify any patient treated during the six months preceding the cessation in order to provide information concerning the established procedure for the retrieval of records.

N.J. Admin. Code § 13:44E-2.2

Amended by 50 N.J.R. 1212(b), effective 5/7/2018