N.J. Admin. Code § 8:43G-15.2

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

Section 8:43G-15.2 - Medical records policies and procedures

(a) The medical record department shall have written policies and procedures that are reviewed at least once every three years, revised more frequently as needed, and implemented. They shall include at least:

1. Procedures for record completion, including chart analysis;

2. Conditions, procedures, and fees for releasing medical information; and

3. Procedures for the protection of medical record information against the loss, tampering, alteration, destruction, or unauthorized use.

(b) All entries in the patient's medical record shall be written legibly in ink, dated, and signed by the recording person or, if a computerized medical records system is used, authenticated.

1. If computer generated orders with a physician's electronic signature are used, the hospital shall develop a procedure to assure the confidentiality of each electronic signature and to prohibit the improper or unauthorized use of any computer generated signature.

2. If a facsimile communications system (Fax) is used, entries into the medical record shall be in accordance with the following procedures:

i. The physician shall sign the original order, history and/or examination at an off-site location;

ii. The original shall be Faxed to the hospital for inclusion into the medical record;

iii. The physician shall submit the original for inclusion into the medical record within 72 hours; and

iv. The faxed copy shall be replaced by the original. Facsimile reports produced by a plain-paper facsimile process can be used as an original document and do not need to be replaced by an original.

(c) Medical records, including outpatient records, shall be organized in a uniform format within each clinical service.

(d) The inpatient's complete medical record shall include at least:

1. Written informed consents, if indicated and documentation of the existence, or nonexistence, of an advance directive and the hospital's inquiry of the patient concerning this;

2. A complete history and physical examination, in accordance with medical staff policies and procedures;

3. Clinical/progress notes;

4. For surgical patients, a preanesthesia note made by the anesthesiologist before administration of anesthesia;

5. For surgical patients, an anesthesia record by the anesthesiologist or certified registered nurse anesthetist;

6. For surgical patients, a postanesthesia note made early in the postoperative period and after release from the recovery room by a member of the hospital's professional anesthesia team in accordance with policies and procedures developed in compliance with 8:43G-35.1(a);

7. For surgical patients, an operative report;

8. A postanesthesia care unit record, if applicable;

9. Consultation reports, where applicable;

10. Physician orders for treatment and medication;

11. Medication record reflecting the drug given, date, time, dosage, route of administration, and signature and status of the person administering the drug. Initials may be used after the person's full signature appears at least once on each page of the medication record. Allergies, including allergy to latex, shall be listed on the medication record;

12. A record of self-administered medications, if the patient self-administers, in accordance with the policies and procedures of the hospital's pharmacy and therapeutic committee, or its equivalent;

13. Reports of laboratory, radiological, and diagnostic services;

14. A discharge summary, which includes the reason for admission, findings, treatment, condition on discharge, medication on discharge, final diagnosis, and, in the case of death, the events leading to death and the cause of death. For cases where the patient is discharged alive within 48 hours of admission and is not transferred to another facility, for normal newborns, and for uncomplicated deliveries, a discharge note may be substituted for the discharge summary. The discharge note includes at least the patient's condition on discharge, medications on discharge, and discharge instructions; and

15. A report of autopsy, if performed by the hospital, with provisional anatomic diagnoses recorded in the medical record within three days. The complete protocol is included in the medical record within the time specified in hospital policies and procedures.

(e) Any adverse incident, including patient injuries, shall be documented in the patient's medical record.

(f) If the patient is transferred to another health care facility (including a home health agency) on a nonemergency basis, the hospital shall maintain a transfer record reflecting the patient's immediate needs and send a copy of this record to the receiving facility at the time of transfer. The transfer record shall contain at least the following information:

1. Diagnoses, including history of any serious physical conditions unrelated to the proposed treatment which might require special attention to keep the patient safe;

2. Physician orders in effect at the time of discharge and the last time each medication was administered;

3. The patient's nursing needs;

4. Hazardous behavioral problems;

5. Drug and other allergies; and

6. A copy of the patient's advance directive, where available.

(g) Medical records shall be completed within 30 days of discharge.

(h) Medical records shall be retained and preserved in accordance with 26:8-5 et seq.

(i) Original medical records of components of medical records shall not leave hospital premises unless they are under court order or subpoena or in order to safeguard the record in case of a physical plant emergency or natural disaster.

(j) Any consent form for medical treatment that the patient signs shall be printed in an understandable format and the text written in clear, legible, nontechnical language. In the case where someone other than the patient signs the forms, the reason for the patient's not signing it shall be indicated on the face of the form, along with the relationship of the signer to the patient.

(k) The patient's death shall be documented in the patient's medical record upon death.

(l) Recording errors in the medical record shall be corrected by drawing a single line through the incorrect entry. The date of correction and legible signature or initials of the person correcting the error shall be included.

(m) All medical records, including outpatient medical records, shall be organized in a uniform format within each clinical service.

N.J. Admin. Code § 8:43G-15.2

Amended by R.1992 d.72, effective 2/18/1992.
See: 23 N.J.R. 2590(a), 24 N.J.R. 590(a).
Electronic and fax order requirements specified at (b)1-2; outpatient records included at (c).
Amended by R.1992 d.132, effective 3/16/1992.
See: 23 N.J.R. 3256(a), 24 N.J.R. 942(a).
Text on documentation of advance directives added at (d) and (e).
Petition for Rulemaking.
See: 25 N.J.R. 3563(d).
Amended by R.1999 d.436, effective 12/20/1999.
See: 31 N.J.R. 367(a), 31 N.J.R. 614(a), 31 N.J.R. 4293(c).
In (a), substituted "at least once every three years, revised more frequently" for "annually, revised" in the introductory paragraph; in (b), added a second sentence in 2iv; in (d), rewrote 6, and inserted a reference to allergy to latex in 11; inserted a new (e); and recodified former (e) through ( l) as (f) through (m).