N.J. Admin. Code § 13:44F-8.2

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

Section 13:44F-8.2 - Patient records

(a) Respiratory care practitioners shall prepare contemporaneous, permanent treatment records. If custody of the patient records is within the responsibility of the licensee, the licensee shall ensure that every patient record shall be kept for at least seven years from the date of the most recent entry, except that if a patient is a minor, the records shall be kept for an additional two years beyond the age of 18. Such records shall include:

1. The dates and times of all treatments including adverse effects, if any;

2. Findings of patient assessment;

3. A patient care plan which includes treatment goals;

4. The chief complaint and diagnosis;

5. Progress notes;

6. Written prescription for care or a care plan signed by a physician or such other health care practitioners authorized by law to prescribe, or a verbal order or prescription memorialized by the prescriber in writing pursuant to the provisions of N.J.A.C. 13:44F-3.1(c) 3. The licensee shall document verbal prescriptions in the patient record contemporaneously with administration of treatment;

7. Results of appropriate tests;

8. In an outpatient setting, a discharge summary which includes the outcome of respiratory care treatment and the status of the patient at the time of discharge; and

9. The signature or initials of the licensee who rendered the care. If the licensee chooses to sign by means of initials, his or her complete signature shall appear at least once in the records.

(b) Respiratory care practitioners shall document any addenda or corrections to a patient's medical record in a separately dated, signed and timed note.

(c) In addition to the requirements of (a) above, a licensee employed in a setting regulated by the Department of Health shall comply with all applicable Department of Health rules.

(d) In an outpatient setting, access to patient treatment records by patients or duly authorized representatives shall be in accordance with the following:

1. Reports of all care and/or tests performed by respiratory care practitioners shall be provided no later than 30 days from the receipt of a written request from the patient or authorized representative. 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, 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, the licensee may elect to provide a summary of the record, as long as that summary adequately reflects the patient's history and treatment.

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 an unpaid balance if the record is needed by another health care professional for the purpose of rendering care.

4. 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.

N.J. Admin. Code § 13:44F-8.2

Amended by 52 N.J.R. 1675(a), effective 9/8/2020