N.J. Admin. Code § 10:161B-18.1

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:161B-18.1 - Maintenance of clinical records

(a) The outpatient substance use disorder treatment program shall establish and implement policies and procedures for production, maintenance, retention, and destruction of clinical records, which shall be reviewed at least annually by the administrator. The policy and procedure manual shall address the written objectives, organizational plan, and quality assurance program for all clinical records, subject to the following:

1. The facility shall establish a clinical record for each client;

2. The facility shall require that documentation of all services provided and transactions regarding the client are entered in his or her clinical record in a uniform manner;

3. The facility shall maintain all clinical records and components thereof on-site at all times unless:

i. The clinical record is removed in accordance with a court order;

ii. The clinical record is removed due to a physical plant emergency or natural disaster; or

iii. Off-site storage of clinical records is approved by DCN&L pursuant to N.J.A.C. 10:161B-18.6; and

4. The facility shall preserve the confidentiality of information contained in the clinical record in accordance with Federal statutes and rules for the Confidentiality of Alcohol and Drug Abuse Client Records at 42 U.S.C. §§ 290dd-2 and 290ee-2 and 42 CFR Part 2, §§ 2.1 et seq. and the provisions of the Health Insurance Portability and Accountability Act (HIPAA) at 45 CFR Parts 160 and 164.

(b) The facility shall establish a record system so that each client's complete clinical record is filed as one unit within 30 days of discharge, with access to and identification of all client clinical records maintained.

(c) The facility shall establish policies and procedures to protect clinical records against loss, tampering, alteration, destruction, unauthorized use or other release of information without the client's consent.

(d) The facility's policies and procedures shall specify the period of time, not to exceed 30 days, within which the clinical record shall be completed following client treatment or discharge.

(e) The facility shall establish policies and procedures regarding the transfer of the client's clinical record information to another health care or treatment facility.

(f) The facility shall establish policies and procedures to provide copies of a client's clinical record to the client, his or her legally authorized representative or a third-party payer where permitted by law or otherwise authorized in writing by the client, consistent with 10:161B-18.5.

N.J. Admin. Code § 10:161B-18.1

Amended by 48 N.J.R. 2791(a), effective 12/19/2016

Amended by 55 N.J.R. 2346(a), effective 11/20/2023