N.J. Admin. Code § 13:44H-9.1

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

Section 13:44H-9.1 - Preparation and maintenance of client records

(a) A licensee shall prepare and maintain for each client a contemporaneous, permanent client record which accurately reflects the client contact with the orthotist, prosthetist, prosthetist-orthotist, orthotist assistant, prosthetist assistant, prosthetist-orthotist assistant or pedorthist, whether in an office, hospital or other evaluation or consultation setting.

(b) A licensee shall include at least the following information in the client record:

1. The client name (on each page of the record), address and telephone number;

2. The location and dates of all treatment, evaluation or consultation settings;

3. The identity of each provider of treatment, evaluation or consultation and the supervisor, if any;

4. The presenting situation;

5. The name and address of the referring physician, podiatrist or dentist;

6. All prescriptions relevant to the client;

7. A treatment or service plan;

8. Contemporaneous progress notes for each session;

9. Fees charged and paid unless a separate financial record is kept; and

10. The name of the manufacturer of any devise not made by the licensee.

(c) The licensee shall periodically review and update the treatment or service plan.

(d) The licensee shall retain the permanent client record for at least seven years from the date of last entry, unless otherwise provided by law.

(e) All licensees shall comply with this section notwithstanding an employer's recordkeeping requirements.

N.J. Admin. Code § 13:44H-9.1

Amended by R.2002 d.196, effective 6/17/2002.
See: 33 New Jersey Register 1864(a), 34 New Jersey Register 2129(a).
In (a), inserted ", orthotist assistant, prosthetist assistant, prosthetist-orthotist assistant" following "prosthetist-orthotist".