N.J. Admin. Code § 13:44E-3.8

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

Section 13:44E-3.8 - Preparation of test report; follow-up

(a) A chiropractic physician who performs an electrodiagnostic test or special examination shall:

1. Prepare and retain a comprehensive report, on professional letterhead bearing the chiropractic physician's full name and license number, office name, address and telephone number, which report shall include at least the following:

i. The patient's name, case identification number, age, sex, height and weight, and dominant side;

ii. The date on which the test was performed;

iii. The location at which the test was performed;

iv. The date on which the report was prepared;

v. A description of the relevant clinical history, including the patient's problem and indication for the testing including the presenting symptoms and clinical signs, etiology of symptoms, history of other diagnostic tests performed and their outcomes;

vi. An identification of the specific test(s) performed and, if applicable, a full description of nerves or muscles sampled, acquisition parameters, appropriate technical attributes of the study such as limb temperature, sites of stimulation, recording of amplitudes and response, latency, configuration of wave forms, distances and velocities, as well as the criteria utilized to identify the reported abnormality;

vii. Data relevant to the test performance, reported in a manner such that another appropriately trained practitioner would be able to interpret the results or replicate the procedure;

viii. Interpretation and comments regarding normality or abnormality of the data which reflects the clinical significance of the data and describes the differential diagnosis and potential etiology for the findings made; and

ix. A statement of diagnostic conclusions and recommendations for appropriate treatment, to include referral to another specialist, if appropriate;

2. Ensure that if technical difficulties were encountered, the report addresses those difficulties, including but not limited to artifact production, non-compliance or agitation by the patient, edema, presence of deformity or scar tissue; and

3. Retain, as part of the patient record, any raw data or graphs arising out of a diagnostic test administration in a form that shall be:

i. Appropriate to the test utilized, for example, copies of wave forms from nerve conduction studies and evoked potentials; and

ii. Available for hard copy review or submission to the Board request, as required by N.J.A.C. 13:44E-2.2.

(b) A chiropractic physician who has requested an electrodiagnostic test or special examination shall obtain from the practitioner who performed the test, in addition to the interpretive report required in (a) above, a representative sample of the wave forms or other raw data, as applicable to the particular test, for inclusion in the patient record.

(c) A chiropractic physician who has performed an electrodiagnostic test or special examination shall discuss the findings and recommendations with the patient or patient's representative, as applicable.

(d) A practitioner who requested that a chiropractic physician perform electrodiagnostic test or special examination may request, with the patient's consent, a second opinion from another licensed chiropractic physician or medical doctor, trained and skilled in the performance and interpretation of electrodiagnostic tests. The patient shall not be caused to incur an additional charge for the second opinion unless the patient specifically consents or the patient's insurance carrier approves such expense as may be incurred. If the consultant to whom the patient is referred intends to charge for the consultation, neither that consultant nor the referring chiropractic physician shall have a significant beneficial interest in the practice of the other.

N.J. Admin. Code § 13:44E-3.8

Amended by R.2007 d.31, effective 2/20/2007.
See: 38 N.J.R. 3235(a), 39 N.J.R. 656(a).
In (a)2, inserted a comma preceding "artifact"; in (a)3, substituted "in a form that" for ", in a form which"; rewrote (b); and in (d), substituted "practitioner" for the first occurrence of "chiropractic physician".