N.J. Admin. Code § 10A:16-2.18

Current through Register Vol. 56, No. 19, October 7, 2024

Section 10A:16-2.18 - Medical records

(a) A complete medical record shall be maintained for each inmate to accurately document all health care services provided throughout the inmate's period of incarceration. The medical record shall consist of an Electronic Health Record (EHR) and a Medical Reference File (MRF). The EHR and/or MRF shall contain the following items:

1. Initial intake medical history;

2. Initial intake physical examination;

3. Health history records;

4. Each health encounter with health care staff including sick call appearances;

5. Progress notes for all health care visitations, treatments, medical findings and diagnoses;

6. Prescribed medications and their administration;

7. Health service reports and consultations, including dental and psychiatric;

8. Prescribed diets and other treatments;

9. Laboratory, x-ray and diagnostic studies;

10. Discharge summary of hospitalizations and other terminations summaries; and

11. Refusal and consent forms.

(b) Only appropriately credentialed and qualified health care staff shall collect and record health history, vital signs and other health appraisal data.

(c) Each health care encounter shall be recorded in the appropriate section of the inmate's EHR. Each entry in the MRF shall be written in black ink or typed, signed or initialed, and clearly dated by the appropriate health care provider staff member. In addition to a physician or health care provider's signature or initials, a name stamp must be used.

(d) All active EHR and MRF records shall be maintained separately from the classification records.

(e) Billing records and parole related mental health evaluations shall be maintained separately from the medical record.

(f) Inactive MRF records shall be stored separately from the active records and in accordance with the retention schedule of the Records Management Program.

(g) MRF records shall accompany inmates when transferred to another correctional facility in order to assure continuity of care and to avoid the duplication of tests and examinations.

(h) Confidentiality of inmate records shall be maintained and records released in accordance with N.J.A.C. 10A:22.

(i) Medical records are maintained in the EHR in accordance with N.J.A.C. 13:35-6.5. Medical records are available to inmates in accordance with provisions at N.J.A.C. 10A:22-2.7.

(j) An inmate may request an amendment or correction of his or her medical record in writing to the responsible health authority. The request must be signed by the inmate and include the following information:

1. The recorded information that the inmate is requesting be amended or corrected;

2. The requested entry representing the amendment or correction to the recorded information that the inmate is seeking;

3. The reason or factual basis for the request of the amendment or correction; and

4. Any other information relevant to the request.

(k) An inmate's request for amendment or correction of his or her medical record shall be considered by the responsible health authority. The inmate shall be notified in writing as soon as possible within 60-calendar days of the receipt of the request to amend or correct the medical record that:

1. The request has been granted and the amendment or correction has been made and the amended or corrected section(s) of the record will be provided to the inmate at no cost to the inmate;

2. The request has been denied along with a written statement of the reasons for the denial; or

3. An extension has been deemed necessary in order to research or obtain additional information relative to the request. In this case, the written notification shall include the reasons for the extension and the reasonable time period within which a response will be provided.

(l) Inmates who disagree with a denial of a request for amendment or correction may utilize the Inmate Remedy System to have the decision reviewed as set forth at N.J.A.C. 10A:1-4.5 and 4.6.

N.J. Admin. Code § 10A:16-2.18

Amended by 49 N.J.R. 2800(a), effective 8/21/2017