Current through Register Vol. 56, No. 18, September 16, 2024
(a) A licensee shall prepare and
maintain separately for each client a contemporaneous, permanent client record that accurately reflects the
client contact with the licensee whether in an office, hospital or other treatment, evaluation or
consultation setting.
(b) The licensee shall include at least the
following information in the client record:
1. The client name (on each
page of the record), address, and telephone number;
2. The
location and dates of all treatment, evaluation, or consultation settings;
3. The identity of each provider of treatment, evaluation, or consultation,
and the supervisor, if any;
4. The presenting
situation;
5. Significant medical and psychosocial
history;
6. Past and current medication, when
appropriate;
7. An assessment of current marriage and family
lifestyle;
8. A diagnostic assessment and prognosis;
9. A treatment plan;
10.
Progress notes for each session;
i. A therapist may dictate progress and
session notes for later transcription provided the transcription is dated and identified as preliminary
pending the therapist's final review and approval.
11.
Information regarding referrals to other professionals and reports and records provided by other
professionals;
12. Fees charged and paid unless a separate
financial record is kept; and
13. A summary of the termination of
services, in accordance with N.J.A.C.
13:34-6.3, including, but not limited to: the reason for termination of
service, a summary of the information provided and topics discussed during the process of terminating
services, the review of the treatment plan, follow-up and transitional services, communication with client
about termination of services, and, as applicable, communication with other mental health professionals
associated with the coordination of treatment.
(c) The
licensee shall periodically review and update the treatment plan.
(d) The licensee shall retain the permanent client record for at least
seven years from the date of the last entry, unless otherwise provided by law, or in the case of a minor, the
licensee shall retain the record until the minor reaches the age of 25.
1.
This requirement shall not apply to a licensee employed in an agency setting if the agency's policy does not
permit a licensee to control the retention of records.
