N.J. Admin. Code § 13:37A-5.4

Current through Register Vol. 56, No. 24, December 18, 2024

Section 13:37A-5.4 - Use of computer to prepare client records

(a) A licensee who prepares a patient record maintained solely on a computer shall use a write-protected program that:

1. Contains an internal permanently activated date and time recordation for all entries;

2. Automatically prepares a back-up copy of the file; and

3. Is designed in such a manner that, after the licensee "signs" by means of a confidential personal code (CPC), the entry cannot be changed in any manner.

(b) The licensee shall include in the client record at least two forms of identification; for example, name and record number of the patient or any other specific identifying information.

(c) The licensee shall finalize or "sign" the entry by means of a CPC. Where more than one individual is authorized to make entries into the computer file of any client record, each such person shall obtain a CPC and uses the program in the same manner.

(d) The licensee shall generate a hard copy of the complete client record, or a portion thereof, upon request.

(e) A licensee who generates a hard copy of a patient record pursuant to (d) above shall ensure that the hard copy is paginated with each page being a specified number of the total number of pages in the record.

N.J. Admin. Code § 13:37A-5.4

Adopted by 51 N.J.R. 1688(a), effective 11/18/2019