Current through Register Vol. 56, No. 18, September 16, 2024
(a) Respiratory care practitioners shall
prepare contemporaneous, permanent treatment records. If custody of the patient
records is within the responsibility of the licensee, the licensee shall ensure
that every patient record shall be kept for at least seven years from the date
of the most recent entry, except that if a patient is a minor, the records
shall be kept for an additional two years beyond the age of 18. Such records
shall include:
1. The dates and times of all
treatments including adverse effects, if any;
2. Findings of patient assessment;
3. A patient care plan which includes
treatment goals;
4. The chief
complaint and diagnosis;
5.
Progress notes;
6. Written
prescription for care or a care plan signed by a physician or such other health
care practitioners authorized by law to prescribe, or a verbal order or
prescription memorialized by the prescriber in writing pursuant to the
provisions of
N.J.A.C.
13:44F-3.1(c) 3. The
licensee shall document verbal prescriptions in the patient record
contemporaneously with administration of treatment;
7. Results of appropriate tests;
8. In an outpatient setting, a discharge
summary which includes the outcome of respiratory care treatment and the status
of the patient at the time of discharge; and
9. The signature or initials of the licensee
who rendered the care. If the licensee chooses to sign by means of initials,
his or her complete signature shall appear at least once in the
records.
(b) Respiratory
care practitioners shall document any addenda or corrections to a patient's
medical record in a separately dated, signed and timed note.
(c) In addition to the requirements of (a)
above, a licensee employed in a setting regulated by the Department of Health
shall comply with all applicable Department of Health rules.
(d) In an outpatient setting, access to
patient treatment records by patients or duly authorized representatives shall
be in accordance with the following:
1.
Reports of all care and/or tests performed by respiratory care practitioners
shall be provided no later than 30 days from the receipt of a written request
from the patient or authorized representative. To the extent that the record is
illegible or prepared in a language other than English, the licensee shall
provide a typed transcription and/or translation at no cost to the
patient.
2. Except where the
complete record is required by applicable law, where the written request comes
from an insurance carrier or its agent with whom the patient has a contract
which provides that the carrier be given access to records to assess a claim
for monetary benefits or reimbursement, the licensee may elect to provide a
summary of the record, as long as that summary adequately reflects the
patient's history and treatment.
3.
A licensee shall provide copies of records in a timely manner to a patient or
another designated health care provider where the patient's continued care is
contingent upon their receipt. The licensee shall not refuse to provide a
patient record on the grounds that the patient owes an unpaid balance if the
record is needed by another health care professional for the purpose of
rendering care.
4. The licensee may
charge a reasonable fee for the reproduction of records, which shall be no
greater than an amount reasonably calculated to recoup the cost of copying or
transcription.
