N.J. Admin. Code § 8:42-11.2

Current through Register Vol. 56, No. 23, December 2, 2024

Section 8:42-11.2 - Medical/health records policies and procedures

(a) An agency shall have written policies and procedures for medical/health records that are reviewed annually, revised as needed, and implemented, and that include at least:

1. Clinical documentation shall be included in the medical/health record within 14 days;

2. Procedures for record completion, including review for accuracy and completion, which shall occur within 45 days;

3. Procedures for the protection of medical record information against loss, tampering, alteration, destruction, or unauthorized removal or use;

4. Conditions, procedures, and fees for releasing medical information; and

5. Release and/or provision of copies of the patient's medical/health record to the patient and/or the patient's authorized representative, including, but not limited to, the following:

i. Establishment of a fee schedule for obtaining copies of the patient's medical/health record; and

ii. Availability of the patient's medical/health record to the patient's authorized representative if it is medically contraindicated (as documented by a physician in the patient's medical/health record) for the patient to have access to or obtain copies of the record.

(b) All entries in the patient's medical/health record shall be typewritten or written legibly in ink, and shall include date, signature, and title, or computer generated with authentication, if an electronic system is used.

1. If a computer rather than a hard copy is used to maintain patient records, an electronic signature generated with authentication may be used.

2. "Authentication" means as that term is defined by the Centers for Medicare and Medicaid Services' Risk Management Handbook, Volume III, Standard 3.1, CMS Authentication Standards, incorporated herein by reference, as amended and supplemented, available on the CMS website at http://www.cms.gov/research-statistics-data-and-systems/cms-information-technology/informationsecurity/downloads/rmh_viii_3-1_auth [File Link Not Available] and must include signatures, written initials, or computer secure entry by a unique identifier of a primary author who has reviewed and approved the entry.

i. The home health agency must have safeguards to prevent unauthorized access to the records and a process for reconstruction of the records in the event of a system breakdown.

3. All forms signed by the patient must be dated and included in the medical record.

(c) A medical/health record shall be initiated for each patient upon admission and shall include at least the following:

1. Patient identification data, including name, date of admission, address, date of birth, sex, race and religion (optional), next of kin, and person to notify in an emergency;

2. Name, address, and telephone number of the patient's physician, an alternate physician, and other primary health care providers if any;

3. AA plan of treatment as defined at 8:42-1.2. This plan shall be:

i. Initiated and implemented when the patient is admitted;

ii. Coordinated and maintained by the nursing service, the physical therapy service, or the speech therapy service, if physical therapy or speech therapy is the sole service;

iii. Inclusive of, but not limited to, the patient's diagnosis, patient goals, means of achieving goals, and care and treatment to be provided;

iv. Current and available to all personnel providing patient care; and

v. Included in the patient's medical/health record.

4. A plan of care as defined at N.J.A.C. 8:42-1.2, including an assessment and plan by each discipline involved in the patient's care;

5. All physician orders;

6. All verbal or telephone orders, which must be countersigned by a physician, advanced practice nurse, or physician assistant within 30 days;

7. Clinical notes;

8. A record of medications if administered, including the name and strength of the drug, date and time of administration, dosage administered, method of administration, and signature of the person who administered the drug.

9. A record of medications shall include action, side effects and contraindications of medications where clinically indicated;

10. Documentation of allergies in the medical/health record;

11. An immunization record, in accordance with the facility's policies and procedures;

12. Written informed consents if indicated;

13. A copy of the patient's advance directive, if available, or documentation of the existence or nonexistence of an advance directive; and documentation of the agency's inquiry to the patient, family, or health care representative regarding this;

14. Documentation of written instructions given to the patient and/or the patient's family;

15. A record of any treatment, medication, or service in the service plan that is not provided and the reason, including patient refusal; and

16. A comprehensive discharge or transfer summary with narrative information from each service as follows:

i. A complete discharge summary that is sent to the primary care physician or other health care professional who will be responsible for providing care and services to the patient after discharge from the CHHA (if any) within five business days of the patient's discharge;

ii. A completed transfer summary that is sent within two business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or

iii. A completed transfer summary that is sent within two business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the CHHA becomes aware of the transfer.

(d) If the patient is transferred to another health care facility, the agency shall maintain a transfer record reflecting the patient's immediate needs and send a copy of this record to the receiving facility at the time of transfer. The Universal Transfer Form, that is required pursuant to N.J.A.C. 8:43E-13, and can be located on the Department's website at http://www.nj.gov/health/forms/hfel-7.pdf.

(e) All consent forms for treatment shall be printed in an understandable format and the text written in clear, legible, nontechnical language.

1. If a family member or other patient representative signs the form, the reason why the patient did not sign it, and the signer's relationship to the patient shall be indicated on the form.

(f) Medical records shall be completed within 45 days of discharge.

(g) The agency shall develop policies and procedures for the removal of the medical/health record, which shall occur only under the following conditions:

1. No medical/health record or parts thereof shall be removed from the agency except for purposes of providing clinical patient care and treatment;

i. Any such record or part thereof which is removed from the agency shall be returned to the agency during the next business day;

2. If there is a court order or subpoena for its release; or

3. To safeguard the record in case of a physical plant emergency or natural disaster; and

4. There shall be a system to protect the security and confidentiality of all components of the medical/health record at all times.

(h) Medical records shall be retained and preserved in accordance with 26:8-5 et seq.

N.J. Admin. Code § 8:42-11.2

Amended by 48 N.J.R. 1445(a), effective 7/18/2016

Amended by 55 N.J.R. 2546(a), effective 12/18/2023