N.J. Admin. Code § 8:111-19.1

Current through Register Vol. 56, No. 12, June 17, 2024

Section 8:111-19.1 - Maintenance of clinical records

(a) The residential substance use disorders treatment facility shall establish and implement policies and procedures for production, maintenance, retention, and destruction of clinical records (including electronic records), which shall be reviewed at least annually by the administrator. The policy and procedure manual shall address the written objectives, organizational plan, and quality assurance program for all clinical records, subject to the following:

1. The facility shall establish a clinical record for each client;

2. The facility shall require that documentation of all services provided and transactions regarding the client are entered in his or her clinical record in a uniform manner;

3. The facility shall maintain all clinical records and components thereof on-site at all times unless:

i. The clinical record is removed in accordance with a court order;

ii. The clinical record is removed due to a physical plant emergency or natural disaster; or

iii. Off-site storage of clinical records is approved by the Division pursuant to N.J.A.C. 8:111-19.6; and

4. The facility shall preserve the confidentiality of information contained in the clinical record in accordance with Federal statutes and rules for the Confidentiality of Alcohol and Drug Abuse Client Records at 42 U.S.C. §§ 290dd-2 and 290ee-2 and 42 CFR Part 2 and the provisions of HIPAA.

(b) The facility shall establish a record system so that each client's complete clinical record is filed as one unit within 30 days of discharge, with access to and identification of all client clinical records maintained.

(c) The facility shall establish policies and procedures to protect clinical records against loss, tampering, alteration, destruction, unauthorized use or other release of information without the client's written consent.

(d) The facility's policies and procedures shall specify the period of time, not to exceed 30 days, within which the clinical record shall be completed following client treatment or discharge.

(e) The facility shall establish policies and procedures regarding the transfer of the client's clinical record information to another health care or treatment facility.

(f) The facility shall establish policies and procedures to provide copies of a client's clinical record to the client, his or her legally authorized representative, or a third-party payer where permitted by law or otherwise authorized in writing by the client, consistent with N.J.A.C. 8:111-19.5.

N.J. Admin. Code § 8:111-19.1

Amended and recodified from 10:161A-19.1 53 N.J.R. 2208(a), effective 12/20/2021