New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 75 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES FOR INDIVIDUALS UNDER AGE 21
Subchapter 1 - GENERAL PROVISIONS
Section 10:75-1.5 - Recordkeeping
Current through Register Vol. 56, No. 18, September 16, 2024
(a) PRTFs shall keep such legible individual records for each resident as are necessary to fully disclose the kind and extent of services provided, as well as the medical necessity for those services. This information shall be available upon the request of the DHS and/or DCF/DCSOC or its authorized agents, including, but not limited to, DMAHS, the Care Management Organization (CMO) and/or the Contracted Systems Administrator (CSA), as well as the Department of Health, and the Centers for Medicare and Medicaid Services (CMS).
(b) An individual record shall be maintained for each Medicaid/NJ FamilyCare DCF/DCSOC resident. The record shall include the individual's medical, nursing, social, and related treatment and care in accordance with this chapter and all accepted professional standards.
(c) All clinical records of discharged residents shall be completed promptly and shall be filed and retained for a period of five years after the discharge of the resident.
(d) If the resident is transferred to or from another PRTF or program, a copy of the resident clinical record, or a summary of the record, shall accompany the resident.
(e) All information contained in the clinical records shall be treated as confidential and shall be disclosed only to authorized persons, including the Department and its agents, DCF/DCSOC, the CSA, and the CMO.
