N.J. Admin. Code § 13:35-10.8

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

Section 13:35-10.8 - Records

(a) A licensed athletic trainer shall prepare and maintain for each athlete a contemporaneous, permanent record that accurately reflects the evaluation and treatment of the athlete's injury by the licensed athletic trainer.

(b) A licensed athletic trainer shall not falsify a record.

(c) A record shall include, in addition to personal identifying information, consents and disclosures, at least the following information:

1. The full name, as it appears on the license, and license number of the licensed athletic trainer who rendered care. This information shall be legible and shall appear at least once on each page of the record;

2. Dates of all athletic training services;

3. The findings of the evaluation including test results;

4. Documentation of health care practitioner referrals, if any;

5. Established measurable goals of the athletic training with stated time frames, the type of athletic training and the frequency and expected duration of athletic training;

6. A contemporaneous note that accurately represents the services rendered during the athletic training sessions including the components of athletic training, the athlete's response to activities and current status;

7. Progress notes in accordance with stated goals at a frequency consistent with the evaluated findings and changes in the athlete's conditions;

8. Communication with other health care professionals relative to the athlete's care;

9. A discharge or return to activity summary, which includes the reason for discharge from and outcome of athletic training relative to established goals at the time of discharge; and

10. Pertinent legal document(s).

(d) Records shall be maintained for at least seven years from the date of the last entry.

(e) A student in a Commission on Accreditation of Athletic Training Education approved athletic training education program may enter information in an athlete's record, as long as the licensed athletic trainer supervising the student co-signs his or her full name and license number next to the student's entry.

(f) A licensed athletic trainer shall maintain his or her plan of care as part of his or her records.

N.J. Admin. Code § 13:35-10.8

Amended by 52 N.J.R. 199(c), effective 2/18/2020