N.J. Admin. Code § 8:111-19.4

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

Section 8:111-19.4 - Contents of clinical records

(a) The facility shall require that all orders for client care be prescribed in writing, signed and dated by the prescriber(s), in accordance with State laws.

1. All medical orders, including verbal and telephone orders, shall be verified by authorized medical personnel or countersigned in writing within 72 hours by the medical director or physician who issued the original order and in accordance with State laws.

(b) The facility shall require that all entries in the clinical record be typewritten or written legibly in black or blue ink, dated and signed by the person entering them, or authenticated if a computerized and/or electronic clinical records system is used.

1. If computer-generated and/or electronic orders with a physician's electronic signature are used, the program shall develop a procedure to ensure the confidentiality of each electronic signature and to prohibit the improper or unauthorized use of any computer-generated signature.

2. If a facsimile communications system (FAX) is used, entries into the clinical record shall be in accordance with the following procedures:

i. The physician shall sign the original order, and include the history and/or examination if conducted at an off-site location;

ii. The original order shall be transmitted by FAX system to the facility for inclusion in the clinical record;

iii. The physician shall submit the original for inclusion in the clinical record within seven days, unless a plain paper laser facsimile process was used; and

iv. The copy transmitted by FAX system shall be replaced by the original, unless a plain paper laser facsimile process was used.

(c) The clinical record shall be completed within the timeframe specified in the clinical records policies and procedures, which shall be no longer than 30 days from the last treatment or discharge.

(d) The clinical record shall be available to the client's substance abuse counselor or clinical treatment staff involved in the client's care at all times during the hours of operation.

N.J. Admin. Code § 8:111-19.4

Amended and recodified from 10:161A-19.4 53 N.J.R. 2208(a), effective 12/20/2021