New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 15 - MEDICAL RECORDS › Section 8:43G-15.3 - Medical record patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Health care
				practitioners who provide clinical services to the patient shall enter
				clinical/progress notes in the patient's medical record, when the services are
				rendered.
(b) Notes that provide a full
				and accurate description of the care provided to the patient shall be made in the
				medical record at the time clinical services are provided. Notes that provide a
				description and an evaluation of the patient's response to treatment shall be made
				in the medical record.
(c) The medical
				record shall either accompany the patient when he or she leaves the patient care
				unit for clinical services in other departments of the hospital or shall be
				retrievable by authorized personnel on a computerized system with a restricted
				access and entry system.
(d) If a
				patient or the patient's legally authorized representative requests, in writing, a
				copy of his or her medical record, a legible, written copy of the record shall be
				furnished at a fee based on actual costs. One copy of the medical record from an
				individual admission shall be provided to the patient or the patient's legally
				authorized representative within 30 days of the request, in accordance with the
				following:
1. The fee for copying records shall
				not exceed $ 1.00 per page or $ 100.00 per record for the first 100 pages. For
				records which contain more than 100 pages, a copying fee of no more than $ 0.25 per
				page may be charged for pages in excess of the first 100 pages, up to a maximum of $
				200.00 for the entire record;
2. In
				addition to per page costs, the following charges are permitted:
i. A search fee of no more than $ 10.00 per
				patient per request. (Although the patient may have had more than one admission, and
				thus more than one record is provided, only one search fee shall be permitted for
				that request. The search fee is permitted even though no medical record is found as
				a result of the search.); and
ii. A
				postage charge of actual costs for mailing. No charges shall be assessed other than
				those permitted in (d)1 and 2 above;
3. The hospital shall establish a policy assuring
				access to copies of medical records for patients who do not have the ability to pay;
				and
4. The hospital shall establish a
				fee policy providing an incentive for use of abstracts or summaries of medical
				records. The patient or his or her representative, however, has a right to receive a
				full or certified copy of the medical record.
5. For purposes of this subsection, "legally
				authorized representative" means the following:
i.
				Spouse, domestic partner or civil union partner;
ii. Immediate next of kin;
iii. Legal guardian;
iv. Patient's attorney;
v. Patient's third party insurer; and
vi. Worker's compensation carriers, where access
				is permitted by contract or law, but limited only to that portion of the medical
				record which is relevant to the specific work-related incident at issue in the
				worker's compensation claim.