N.J. Admin. Code § 13:44-4.9

Current through Register Vol. 56, No. 23, December 2, 2024

Section 13:44-4.9 - Patient records

(a) A licensee shall maintain a separate patient record for each animal, herd, flock, or any other aggregation of animals. All patient records shall accurately reflect the treatment or services rendered. Such records shall include at least the following information:

1. The name of the facility, which shall appear on every page of the record;

2. The name, initials or other identifying information to indicate the identity of the licensee or agent making the entry in the patient record and the date on which the entry is made;

3. The name, address and telephone number of the owner of the animal;

4. Sufficient information to clearly identify the animal, herd or flock (for example, animal name or tattoo, breed or predominant breed species);

5. A history of the presenting problem;

6. All pertinent symptoms and signs observed;

7. Tests ordered or performed and the results thereof;

8. Conclusions and/or diagnosis;

9. The treatment or treatment plan prescribed, including a specific notation of any medications or modalities prescribed;

10. Such other notes or information so as to provide a clear statement of the patient's condition and the veterinary evaluation and response; and

11. Copies of any consent forms signed by the owner or the owner's representative.

(b) A licensed veterinarian shall keep records confidential, unless:

1. The licensed veterinarian is required by law to release the records;

2. The Board requests the records;

3. The client, at the time services were rendered by the licensed veterinarian, authorizes the licensed veterinarian to release the records; or

4. It becomes necessary to release information in the records in order to protect the health of a person, the animal that is the subject of the records or another animal.

(c) A licensee may require that a record request be in writing and may charge a fee for the reproduction of records, which shall be no greater than $ 1.00 per page or $ 100.00 for the entire record, whichever is less. If the record requested is less than 10 pages, the licensee may charge up to $ 10.00 to cover postage and the costs associated with retrieval of the record.

(d) A licensee shall only release diagnostic imaging, such as a radiograph, pursuant to (b) above. A licensee who obtains a copy of diagnostic imaging may charge a fee that covers the cost of obtaining the copy. A licensee who releases diagnostic imaging shall keep, as part of his or her records:

1. A copy or original of the diagnostic imaging;

2. A release form signed by the individual to whom an original diagnostic imaging is released, indicating that he or she has taken the diagnostic imaging and will return the diagnostic imaging to the licensee; or

3. A certified radiologist's report on the diagnostic imaging.

(e) All records and radiographs on patients shall be retained for a period of five years from the date of the patient's last visit except as provided in (h) or (i) below. Where the records reflect the decease of the patient, all written records and radiographs shall be retained for a period of three years from the last date of entry.

(f) Copies of a licensee's record or a summary report of such record and copies of all pertinent objective data and papers pertaining to a given patient, along with a key to any codes, abbreviations and non-English words appearing on such record, data or papers, shall be furnished to the patient's owner, a designated representative or a designated veterinarian within 10 business days of a written request by the owner or duly authorized representative. A licensee may charge a fee pursuant to (c) above for providing copies of records.

(g) When a patient's life or health is in danger, a licensee shall release information pertinent to the critical care of the patient to the patient's owner, a representative designated by the owner or a veterinarian designated by the owner, immediately upon receiving a request for the information.

(h) Where services are rendered on an emergency basis by a veterinary facility and the patient is referred to the owner's regular veterinarian for continued treatment, the veterinarian rendering such emergency treatment shall release the medical records and radiographs to the owner or the regular veterinarian; provided, however, that the emergency treatment facility shall obtain a written receipt if originals are released, showing the disposition of the records and shall keep the receipt for a period of two years.

(i) Whenever a veterinary practice is to be closed due to the retirement or death of the veterinarian in charge, or the practice will be closed for more than six consecutive months, the licensee or the executor or administrator of the licensee's estate shall:

1. Establish a procedure by which patients may obtain treatment records or agree to the transfer of those records to another licensee who is assuming the responsibilities of that practice;

2. If the practice will not be attended by another licensee, publish a notice of the cessation and the established procedure for the retrieval of records in a newspaper of general circulation in the geographic location of the licensee's practice, at least once each month for the first three months after the cessation;

3. Notify the Board, in writing, of the impending closure and the established procedure for the retrieval of records;

4. Make reasonable efforts to directly notify the owner of any patient treated during the six months preceding the cessation of the practice to provide information concerning the established procedure for retrieval of records;

5. Conspicuously post a notice on the premises of the procedure for the retrieval of records for at least one month prior to the cessation of the practice; and

6. Arrange for the storage of any records that have not been retrieved by patient owners for one year from the date the practice closes.

N.J. Admin. Code § 13:44-4.9

Amended by 50 N.J.R. 906(b), effective 2/20/2018