N.J. Admin. Code § 10:161B-18.6

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

Section 10:161B-18.6 - Preservation, storage, and retrieval of clinical records

(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.

N.J. Admin. Code § 10:161B-18.6

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

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