N.J. Admin. Code § 13:42A-6.1 - Preparation and maintenance of patient records

(a) A State-certified psychoanalyst shall contemporaneously prepare and maintain separately for each patient a permanent record, which accurately reflects the State-certified psychoanalyst's contact with the patient whether in an office, hospital or other treatment, evaluation or consultation setting.

(b) A State-certified psychoanalyst shall include in the patient record the following information pertinent to the nature and extent of the professional interaction between the State-certified psychoanalyst and the patient:

1. The patient's name, address and telephone number;

2. The patient's complaint on intake;

3. Initial and ongoing diagnostic impressions;

4. Dates of all treatment, evaluation or consultation sessions and progress or session notes, if any;

5. The client identity on each page;

6. Fees charged and paid; and

7. In a multi-person practice, the identity of each provider of treatment, evaluation or consultation.

(c) The patient record shall contain information regarding referrals to other professionals.

(d) When records are to be maintained as confidential, the State-certified psychoanalyst shall establish and maintain a procedure to protect such records from access by unauthorized persons.

(e) The State-certified psychoanalyst shall retain the permanent patient record for at least seven years from the date of last entry, unless otherwise provided by law.

Notes

N.J. Admin. Code § 13:42A-6.1