N.J. Admin. Code § 8:43A-13.1

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

Section 8:43A-13.1 - Maintenance of medical records

(a) A current, complete medical record shall be established and maintained for each patient and shall contain documentation of all services provided.

(b) Written objectives, policies and procedures, an organizational plan, and a quality assurance program for medical record services shall be developed and implemented. All medical records policies and procedures shall be reviewed at least annually.

(c) Original medical records or components of medical records shall not leave facility premises unless they are under court order or subpoena or removed in order to safeguard the record in the case of a physical plant emergency or natural disaster. Off-site storage of records may be used only if the Department is given prior notice, including the details of the storage arrangement, and only if such storage arrangements will ensure retrieval and delivery of the patient's medical record to the facility within one business day on a seven day per week, 24 hour per day, basis and immediate availability of medical record information through telephone and facsimile communications systems.

(d) A record system shall be maintained in which the patient's complete medical record is filed as one unit, and there shall be a system of access and identification for the medical records of all patients.

N.J. Admin. Code § 8:43A-13.1