N.J. Admin. Code § 13:45A-35.10

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

Section 13:45A-35.10 - Recordkeeping

(a) Each practitioner and each authorized faculty member of a medical or dental teaching facility who designates a delegate shall establish, retain, and follow written procedures to document, as part of the patient record, the PMP look-up as required in N.J.A.C. 13:45A-35.9 and any PMP information accessed for the patient.

1. Each delegate shall follow the documentation procedures established by his or her delegating practitioner.

2. Examples of documentation include a summary notation of the information reviewed by the practitioner or the printed PMP report in the patient record.

3. Once PMP information is documented in the patient record, disclosure of such information is governed by applicable State laws, other than 45:1-45, and Federal laws, including the Federal Health Insurance Portability and Accountability Act of 1996 and the Federal health privacy rule set forth at 45 CFR Parts 160 and 164.

(b) A practitioner or an authorized faculty member of a medical or dental teaching facility who designates a delegate shall establish, retain, and follow written procedures to document:

1. Verification of each delegate's education, training, and licensure or certification requirements, as required in N.J.A.C. 13:45A-35.8(d); and

2. The bi-annual audit, as required in N.J.A.C. 13:45A-35.8(e)3.

(c) The program director of the medical or dental residency program shall retain records of the faculty members authorized to designate a medical or dental resident, as applicable, as a delegate.

(d) Each mental health practitioner shall retain in the patient record a copy of the patient consent, and any PMP information accessed for the patient.

(e) All records required to be maintained in this subchapter shall be made available to the Division upon request.

N.J. Admin. Code § 13:45A-35.10

Adopted by 48 N.J.R. 2374(a), effective 11/7/2016

Amended by 50 N.J.R. 1500(a), effective 7/2/2018