N.J. Admin. Code § 8:43F-15.4

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

Section 8:43F-15.4 - Medical records policies and procedures

(a) All orders for participant care shall be prescribed in writing and signed and dated by the prescriber.

(b) All entries in the participant's medical record shall be written legibly in ink, dated, and signed by the recording person or, if a computerized medical records system is used, authenticated.

1. If an identifier such as a master sign-in sheet is used, initials may be used for signing documentation, in accordance with applicable professional standards of practice.

2. If computer-generated orders with an electronic signature are used, the facility shall develop a procedure to assure the confidentiality of each electronic signature and to prohibit the improper or unauthorized use of computer-generated signatures.

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

i. The physician, advanced practice nurse or physician assistant shall sign the order, history and/or examination at an off-site location;

ii. The order or document shall be faxed to the facility for inclusion into the medical record;

iii. The physician, advanced practice nurse or physician assistant shall submit the original for inclusion into the medical record within seven days; and

iv. The faxed copy shall be replaced by the original. If the facsimile reports are produced by a plain-paper facsimile process that produces a permanent copy, the plain-paper report may be included as a part of the medical records, as an alternative to replacement of the copy by the original report.

(c) If a participant or the participant's legally authorized representative requests in writing a copy of his or her medical record, a legible photocopy of the record shall be furnished at a fee based on actual costs, which shall not exceed prevailing community rates for photocopying. A copy of the medical record shall be provided to the participant or the participant's legally authorized representative within 30 days of request.

1. The facility shall establish a policy assuring access to copies of medical records for participants who do not have the ability to pay.

2. The facility shall establish a fee policy providing an incentive for use of abstracts or summaries of medical records. The participant or his or her authorized representative, however, has a right to receive a full or certified copy of the medical record.

(d) Access to the medical record shall be limited only to the extent necessary to protect the participant. A verbal explanation for any denial of access shall be given to the participant or legally authorized representative by the physician, advanced practice nurse or physician assistant and there shall be documentation of this in the medical record. In the event that direct access to a copy by the participant is medically contraindicated (as documented by a physician, advanced practice nurse or physician assistant in the participant's medical record), the medical record shall be made available to a legally authorized representative of the participant or the participant's physician, advanced practice nurse or physician assistant.

(e) The participant shall have the right to attach a brief comment or statement to his or her medical record after completion of the medical record.

(f) The record shall be protected against loss, destruction, or unauthorized use. Medical records shall be retained for a period of 10 years following the most recent discharge of the participant. A summary sheet shall be retained for a period of 20 years, and X-ray films or reproductions thereof shall be retained for a period of five years, in accordance with 26:8-5.

(g) The facility shall develop policies regarding the specific period of time within which the medical record shall be completed following participant discharge and disciplinary action for non-compliance.

(h) The facility shall develop a procedure for the transfer of participant information when the participant is transferred to another health care facility.

(i) If the facility plans to cease operation, it shall notify the Department in writing, at least 14 days before cessation of operation, of the location where medical records will be stored and of methods for their retrieval.

N.J. Admin. Code § 8:43F-15.4