New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 161B - STANDARDS FOR LICENSURE OF OUTPATIENT SUBSTANCE USE DISORDER TREATMENT FACILITIES
Subchapter 18 - CLINICAL RECORDS
Section 10:161B-18.6 - Preservation, storage, and retrieval of clinical records

Universal Citation: NJ Admin Code 10:161B-18.6

Current through Register Vol. 56, No. 18, September 16, 2024

(a) The facility shall preserve all clinical records in accordance with 26:8-5 for a period of 10 years following the most recent discharge of the client, or until he or she reaches 23 years, whichever is longer. In addition, a discharge/continuum of care summary sheet shall be retained by such custodian of records for a period of 20 years following the most recent discharge of the client. The discharge summary sheet shall contain the client's name, address, date(s) of admission and discharge and a summary of the treatment and medication rendered during the client's stay.

(b) If the facility plans to cease operation, it shall notify DCN&L, in writing, at least 14 days before cessation of operation, of the location where clinical records shall be stored and of methods for their retrieval.

1. The facility shall store all clinical records on-site unless off-site storage is approved by DCN&L.

2. DCN&L shall approve off-site storage if the notice from the facility requesting approval ensures that off-site storage shall maintain:
i. Retrieval and delivery of clinical records within one business day following request, seven days per week, 24 hours per day; and

ii. Immediate availability of clinical record information through telephone and facsimile communications systems.

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