N.J. Admin. Code § 13:35-12.18

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

Section 13:35-12.18 - Recordkeeping

(a) Licensees shall make contemporaneous, permanent entries into client records which shall accurately reflect the electrology services rendered. Client records shall be maintained for a period of seven years from the date of the most recent entry. The client record shall contain:

1. A Health History Assessment, only to the extent that it relates to the practice of electrology;

2. The dates and duration of each treatment;

3. The client's presenting problem and/or condition;

4. The name of the treating electrologist if there is more than one electrologist practicing at the office;

5. Areas treated, size of needle, modality and settings;

6. Progress notes;

7. Any referral to a physician; and

8. Fees charged and paid.

(b) Corrections and/or additions may be made to a client record, provided that each change is clearly identified as such, dated and initialed by the licensee.

(c) A client record which is prepared and maintained on a personal or other computer shall be producible as hard copy upon demand.

(d) Licensees shall provide a copy of a client treatment record to a client or an authorized representative no later than 30 days from receipt of a written request from the client or an authorized representative.

(e) Licensees shall maintain the confidentiality of professional treatment records, except that:

1. The licensee shall release client records as directed by a subpoena issued by the Board of Medical Examiners or the Office of the Attorney General, or by a demand for statement in writing under oath, pursuant to 45:1-18. Such records shall be originals, unless otherwise specified, and shall be unedited, with full client names; and

2. The licensee shall release information as required by law or regulation.

N.J. Admin. Code § 13:35-12.18