N.J. Admin. Code § 13:44G-12.1

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

Section 13:44G-12.1 - Preparation and maintenance of client records

(a) A social worker shall prepare and maintain for each client a contemporaneous, permanent client record that accurately reflects the client contact with the social worker whether in an office, hospital or other treatment, evaluation or consultation setting.

(b) A social worker shall include at least the following information in the client record:

1. The client name (on each page of the record), address and telephone number;

2. The location and dates of all treatment, evaluation or consultation settings;

3. The identity of each provider of treatment, evaluation or consultation and the supervisor, if any;

4. The presenting situation;

5. Significant social history;

6. Past and current medications, when appropriate;

7. A social work assessment, unless a separate record is kept;

8. A treatment or service plan;

9. Progress notes for each session;

i. A social worker may dictate progress and session notes for later transcription provided the transcription is dated and identified as preliminary pending the social worker's final review and approval;

10. Information regarding referrals to other professionals and reports and records provided by other professionals; and

11. Fees charged and paid unless a separate financial record is kept.

(c) A social worker providing clinical services shall include in the client record the following information, in addition to the information required pursuant to (a) above:

1. Significant medical and psychosocial history;

2. A diagnostic assessment; and

3. Prognosis.

(d) The social worker shall periodically review and update the treatment or service plan.

(e) The social worker shall retain the permanent client record for at least seven years from the date of the last entry, unless otherwise provided by law, or in the case of a minor, until age 25.

1. This requirement shall not apply to a social worker in an agency setting where it is not the policy of the agency to allow the social worker to maintain control over the retention of client records.

N.J. Admin. Code § 13:44G-12.1

Amended by R.1998 d.66, effective 1/20/1998.
See: 29 N.J.R. 4388(a), 30 N.J.R. 372(b).
In (b)7, added ", unless a separate record is kept"; and in (e), added i.
Amended by R.2003 d.265, effective 7/7/2003.
See: 35 N.J.R. 380(a), 35 N.J.R. 2936(b).
Deleted (f).
Administrative correction.
See: 40 N.J.R. 6471(a)