N.J. Admin. Code § 13:35-14.15 - Recordkeeping

(a) Licensed genetic counselors shall make contemporaneous, permanent entries into client records, which shall accurately reflect the genetic counseling services rendered. Client records shall be maintained for a period of seven years from the date of the most recent entry. The client record shall contain, at a minimum:

1. Intake record;

2. The dates of each service;

3. Reasons for visits;

4. A summary of each session with an assessment and plan;

5. The name and title of the licensed genetic counselor or permitted genetic counselor who provided services;

6. The licensed genetic counselor's or permitted genetic counselor's initials for every entry to the records; and

7. Any referral to another healthcare professional.

(b) Corrections and/or additions to existing records may be made to a client record, provided that each change is clearly identified as such, and such is dated and initialed by the licensed genetic counselor making the change.

Notes

N.J. Admin. Code § 13:35-14.15