New Jersey Administrative Code › Title 13 - LAW AND PUBLIC SAFETY › Chapter 35 - BOARD OF MEDICAL EXAMINERS › Subchapter 6 - GENERAL RULES OF PRACTICE › Section 13:35-6.5 - Preparation of patient records, computerized records, access to or release of information; confidentiality, transfer or disposal of records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following terms shall have the following meanings unless the context in which they appear indicates otherwise:
"Authorized representative" means, but is not necessarily limited to, a person who has been designated by the patient or a court to exercise rights under this section. An authorized representative may be the patient's attorney or an employee of an insurance carrier with whom the patient has a contract which provides that the carrier be given access to records to assess a claim for monetary benefits or reimbursement. If the patient is a minor, a parent or guardian who has custody (whether sole or joint) will be deemed to be an authorized representative, except where the condition being treated relates to pregnancy, sexually transmitted disease or substance abuse.
"Examinee" means a person who is the subject of professional examination where the purpose of that examination is unrelated to treatment and where a report of the examination is to be supplied to a third party.
"Licensee" means any person licensed or authorized to engage in a health care profession regulated by the Board of Medical Examiners.
"Patient" means any person who is the recipient of a professional service rendered by a licensee for purposes of treatment or a consultation relating to treatment.
(b) Licensees shall prepare contemporaneous, permanent professional treatment records. Licensees shall also maintain records relating to billings made to patients and third-party carriers for professional services. All treatment records, bills and claim forms shall accurately reflect the treatment or services rendered. Treatment records shall be maintained for a period of seven years from the date of the most recent entry.
1. To the extent applicable, professional treatment records shall reflect:
i. The dates of all treatments;
ii. The patient complaint;
iii. The history;
iv. Findings on appropriate examination;
v. Progress notes;
vi. Any orders for tests or consultations and the results thereof;
vii. Diagnosis or medical impression;
viii. Treatment ordered, including specific dosages, quantities and strengths of medications including refills if prescribed, administered or dispensed, and recommended follow-up;
ix. The identity of the treatment provider if the service is rendered in a setting in which more than one provider practices;
x. Documentation when, in the reasonable exercise of the physician's judgment, the communication of test results is necessary and action thereon needs to be taken, but reasonable efforts made by the physician responsible for communication have been unsuccessful; and
xi. Documentation of the existence of any advance directive for health care for an adult or emancipated minor, and associated pertinent information. Documented inquiry shall be made on the routine intake history form for a new patient who is a competent adult or emancipated minor. The treating doctor shall also make and document specific inquiry of or regarding a patient in appropriate circumstances, such as when providing treatment for a significant illness, or where an emergency has occurred presenting imminent threat to life, or where surgery is anticipated with use of general anesthesia.