N.J. Admin. Code § 8:43J-14.4

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

Section 8:43J-14.4 - Medical records policies and procedures

(a) All orders for child-care shall be prescribed in writing and signed and dated by the prescriber.

1. All medication orders shall be in compliance with 8:43J-9.2.

(b) All entries in the child'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 an identifier, such as a master sign-in sheet is used, initials may be used for signing documentation, in accordance with applicable professional standards of practice.

2. If computer-generated orders with an electronic signature are used, the facility shall develop a procedure to assure the confidentiality of each electronic signature and to prohibit the improper or unauthorized use of computer-generated signatures.

3. If a telefacsimile communications system is used, entries into the medical record shall be in accordance with the following procedures:

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

ii. The order or document shall be transmitted by telefacsimile to the facility for inclusion into the medical record;

iii. The prescriber shall submit the original order or document for inclusion into the medical record within seven days; and

iv. The original order or document shall replace the order or document transmitted by telefacsimile.

(1) If the order or document transmitted by telefacsimile is produced by a plain-paper telefacsimile process that produces a permanent copy, the plain-paper order or document may be used as part of the medical record, as an alternative to replacement of the original order or document.

(c) If a child's parent requests in writing a copy of the child's medical record, the facility shall provide a legible photocopy of the record within 30 days of request at a fee based on actual cost, which shall not exceed prevailing community rates for photocopying.

1. The facility shall establish a policy assuring access to copies of medical records for children whose parents do not have the ability to pay.

2. The facility shall establish a fee policy providing a means for use of abstracts or summaries of medical records, provided the child and/or his or her authorized representative shall have a right to receive a full copy of the medical record.

(d) The facility shall establish policies regarding the specific period of time within which the medical record shall be completed following child discharge and disciplinary action for non-compliance.

(e) The facility shall develop a procedure for the transfer of child information when the child is transferred to another health care facility.

(f) If the facility plans to cease operation, it shall notify the Department in writing, at least 14 days before cessation of operation, of the location at which medical records will be stored and of methods for their retrieval.

N.J. Admin. Code § 8:43J-14.4