N.J. Admin. Code § 8:43A-13.5

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

Section 8:43A-13.5 - Medical records policies and procedures

(a) The facility shall establish and implement written policies and procedures regarding medical records including, but not limited to, policies and procedures for the following:

1. The protection of medical record information against loss, tampering, alteration, destruction, or unauthorized use. The patient's written consent shall be obtained for release of medical record information;

2. The specific period of time, not to exceed 30 days, within which the medical record shall be completed following treatment or discharge; and

3. The transfer of patient information when the patient is transferred to another health care facility, or if the patient has been an inpatient and becomes an outpatient at the same facility, to ensure continuity of care.

(b) A patient, the patient's legally authorized representative, or a third-party insurer as permitted by law may request or authorize, in writing, that a copy of the patient's medical record be provided to one of them or released to a third party. The ambulatory care facility or its subcontractor shall furnish a legible, written copy of the record at a fee based on actual costs. ("Legally authorized representative" within this section means spouse, domestic partner, civil union partner, immediate next of kin, legal guardian, executor, or an individual with power of attorney.) A copy of the medical record from an individual admission shall be provided within 30 days of request, in accordance with the following:

1. The fee for copying records shall not exceed $ 1.00 per page or $ 100.00 per record for the first 100 pages. For records which contain more than 100 pages, a copying fee of no more than $ 0.25 per page may be charged for pages in excess of the first 100 pages, up to a maximum of $ 200.00 for the entire record;

2. In addition to per page costs, the following charges are permitted:

i. A search fee of no more than $ 10.00 per patient per request; and

ii. A postage charge of actual costs for mailing, not to exceed $ 5.00;

3. No charges shall be assessed other than those permitted in (b)1 and 2 above;

4. The facility shall establish a policy assuring access to copies of medical records for patients who do not have the ability to pay; and

5. The facility shall establish a fee policy providing an incentive for use of abstracts or summaries of medical records. The patient or his or her authorized representative, however, has a right to receive a full or certified copy of the medical record.

(c) The Department shall periodically reevaluate the reasonableness of the fee scale contained in (b) above. If the Department determines that a change to the fee scale is warranted, the Department shall propose an amendment to (b) above.

(d) Access by the patient to the medical record shall be limited only to the extent necessary to protect the patient. A verbal explanation for any denial of access shall be given to the patient or legal guardian by the physician, and there shall be documentation of this in the medical record. In the event that direct access to a copy by the patient is medically contraindicated (as documented by a physician in the patient's medical record), the medical record shall be made available to a legally authorized representative of the patient or the patient's physician.

N.J. Admin. Code § 8:43A-13.5

Amended by R.2008 d.24, effective 1/22/2008.
See: 39 N.J.R. 2309(a), 40 N.J.R. 702(a).
In the introductory paragraph of (b), inserted a hyphen following "third", inserted "domestic partner, civil union partner," and substituted "as" for "where".