N.J. Admin. Code § 13:34-18.1 - Preparation and maintenance of client records

(a) A licensee shall prepare a permanent client record for each client which accurately reflects the client contact with the licensee whether in an office, hospital, agency or other treatment, evaluation or consultation setting.

(b) A licensee shall make entries in the client record contemporaneously with the services provided. A licensee may dictate an entry for later transcription, provided the transcription is dated and identified as "preliminary" until the licensee reviews the transcription and finalizes the entry in the client record.

(c) The licensee shall include in the client record material pertinent to the nature and extent of the professional interaction, which shall include:

1. The client name, address and telephone number;

2. The client complaint on intake;

3. Medical history recognized as of potential significance;

4. Past and current medications;

5. Significant social history;

6. Findings on appropriate examination;

7. Raw data and interpretation of tests, if administered;

8. Current functional impairments and rating levels thereof;

9. A diagnostic impression;

10. Contemporaneous and dated progress or session notes including specific components of treatment, evaluation or consultation;

11. Dates of all treatment, evaluation or consultation sessions;

12. The location of treatment, evaluation or consultation;

13. An evaluation of progress (if applicable);

14. A prognosis;

15. The client identity on each page;

16. Fees charged and paid;

17. The identity of each provider of treatment, evaluation or consultation (and supervisor, if any);

18. If services are rendered by an associate counselor, the written disclosure form signed by the client; and

19. Information regarding referrals to other professionals.

(d) The client record shall contain the written disclosure form required pursuant to N.J.A.C. 13:34-13.2(b) and reports and records provided by other professionals and integrated into the client's treatment, evaluation or consultation report.

(e) A licensee may make corrections or additions to an existing record provided that each change is clearly identified as such, dated and initialed by the licensee. Any other alteration of records shall be deemed professional misconduct.

(f) When records are to be maintained as confidential, the licensee shall establish and maintain a procedure to protect such records from access by unauthorized persons.

(g) The licensee shall retain the permanent client record for at least seven years from the date of last entry, unless otherwise provided by law.

(h) The licensee shall establish reasonable procedures for maintaining the confidentiality of client records in the event of the licensee's relocation, retirement, termination from practice, death, or separation from a group practice, and shall establish reasonable procedures to assure the preservation of client records which shall include at a minimum:

1. Establishment of a procedure by which patients can obtain treatment records or acquiesce in the transfer of those records to another licensee or health care professional who is assuming the responsibilities of that practice; and

2. Making reasonable efforts to directly notify any patient treated during the six months preceding the cessation, and providing information concerning the established procedure for retrieval of records.

(i) Subsections (f) through (h) above shall not apply to a licensee employed in an agency setting which does not, by agency policy, have control over client records.

Notes

N.J. Admin. Code § 13:34-18.1

Amended by 49 N.J.R. 655(a), effective 4/3/2017