N.J. Admin. Code § 13:44E-3.4

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

Section 13:44E-3.4 - Basic pre-test prerequisites and standards for patient evaluation applicable to electrodiagnostic tests and special examinations

(a) A chiropractic physician performing or interpreting electrodiagnostic tests and special examinations shall:

1. Adhere to accepted standards of practice applicable to the performance of such tests relating to clinical justification, reliability, validity, performance technique, interpretation and integration into the plan of treatment;

2. Ensure that tests, if performed by a chiropractic physician, are performed personally or under his or her immediate personal supervision and direction;

3. Assure that professionally responsible and scientifically sequential pre-testing determinations are followed;

4. Take and document, in the patient's record, a relevant history of the complaints presented by the patient. Chiropractic records shall meet acceptable clinical standards and contain such pertinent information including height, weight, past medical and surgical history and other information that may influence the outcome or interpretation of the testing;

5. Perform, at a minimum, a problem-focused examination;

6. Establish and document in the patient's record, a provisional diagnosis with clinical correlation; and

7. Abide by appropriate standards of informed consent explaining potential risks, potential benefits and other clinical options.

(b) A chiropractic physician requesting the performance of electrodiagnostic tests and other special examinations with respect to a specific patient shall first:

1. Take and document in the patient record a history of the patient's clinical condition, reflecting:

i. Responses to inquiries regarding prior disease, trauma, surgery, prior and current medications prescribed by other practitioners, use of orthopedic devices and other relevant information, as applicable to the patient's situation;

ii. Factors which may be contributing to the patient's pain, sensory or motor complaints; and

iii. Pertinent information such as the patient's current height and weight, employment (including physical requirements, whether in or outside the home) and relevant aspects of required work effort, known injuries, testing performed and results, care received, response and other factors which may be relevant to the patient's condition;

2. Perform and document in the patient record a clinical examination including subjective complaints, observations, objective findings from a neurologically oriented physical examination, tests performed and their results including x-ray interpretation, interpretive reports of imaging studies acquired from any source, and interpretive reports of any other testing;

3. Establish and document in the patient record a provisional diagnosis and plan of care;

4. Prepare and document in the patient record ongoing progress notes reflecting subjective complaints, objective findings, treatment provided, and the patient's objective and subjective response to the treatment provided; and

5. Discuss with the patient appropriate alternatives and options, including referral to another practitioner or specialist for consultation and evaluation.

(c) A chiropractic physician who has complied with the requirements of (b)1 through 5 above may request electrodiagnostic tests or special examinations if the results of tests selected are expected to:

1. Alter the course of the patient's treatment;

2. Aid in determining the extent of functional deficit present; and

3. Be useful in the assessment of deterioration or improvement of a condition for the purpose of continued care.

(d) A chiropractic physician who has complied with the requirements of (b)1 through 5 above may refer a patient to another chiropractic physician or other appropriately licensed and trained practitioner to determine the need for, and the performance and interpretation of, an electrodiagnostic test or a special examination by means of a request for professional consultation, provided the referring chiropractic physician:

1. Thoroughly documents in the patient record an appropriate scientific rationale for the referral; and

2. Directly communicates with the practitioner who is to perform the test, prior to the referral, as is professionally appropriate in the circumstances.

N.J. Admin. Code § 13:44E-3.4

Amended by R.2007 d.31, effective 2/20/2007.
See: 38 N.J.R. 3235(a), 39 N.J.R. 656(a).
In the introductory paragraph of (a), deleted ", requesting" following "performing"; in (a)1, deleted a comma after "tests"; in (a)2, deleted "and" from the end; in (a)3, substituted a semicolon for the period at the end; added (a)4 through (a)7; in the introductory paragraph of (b), substituted "requesting" for "contemplating"; in the introductory paragraph of (c), substituted "request" for "perform" and deleted a comma following "examinations"; and in (d)2, inserted a comma following "test".