N.J. Admin. Code § 13:37A-5.2 - Recordkeeping

(a)Licensees shall make contemporaneous, permanent entries into client records that shall accurately reflect the massage and bodywork services rendered. Client records shall be maintained in a safe and secure location 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, including a physician's prescription, if there is one;

4. The name of the licensee who provided services if there is more than one licensee practicing at the office;

5. Modalities used and areas of focus on the body; and

6. Any referral to another healthcare professional.

(b) A licensee may make corrections and/or additions to a client record, provided that each change is clearly identified as such, dated and initialed by the licensee.

Notes

N.J. Admin. Code § 13:37A-5.2

Amended by 51 N.J.R. 1688(a), effective 11/18/2019