N.J. Admin. Code 8:43G-15.2 - Medical records policies and procedures

The medical record department’s written policies and procedures, that are implemented and revised as needed, will be reviewed at least once every three years. The policies will include procedures for record completion, including chart analysis, conditions, procedures, and fees for releasing medical information, and procedures for the protection of medical record information against the loss, tampering, alteration, destruction, or unauthorized use.

All entries in a medical record must be written legibly in ink, dated, and signed by the recorder or, if a computerized medical records system is used, authenticated. Hospitals must develop an authentication procedure for computer generated orders using electronic signatures that protects the confidentiality and proper use of said signatures.

When fax is used in connection with medical records, the physician shall sign the original entry at an off-site location, fax the original to the hospital for inclusion in the medical record, submit the original entry for inclusion in the record within 72 hours, and replace the fax copy with the original.

Medical records, including outpatient records, must be uniformly organized. A complete inpatient medical record must include:

• Written informed consents, if indicated and documentation of the existence, or nonexistence, of an advance directive and the hospital's inquiry of the patient concerning this;
• A complete history and physical examination, in accordance with medical staff policies and procedures;
• Clinical/progress notes;
• For surgical patients, a preanesthesia note made by the anesthesiologist before administration of anesthesia, an anesthesia record by the anesthesiologist or certified registered nurse anesthetist, a postanesthesia note made early in the postoperative period and after release from the recovery room by a member of the hospital's professional anesthesia team in accordance with policies and procedures developed in compliance with N.J.A.C. 8:43G-35.1(a), and an operative report;
• A postanesthesia care unit record, if applicable;
• Consultation reports, where applicable;
• Physician orders for treatment and medication, where the medication record reflects the drug given, date, time, dosage, route of administration, and signature and status of the person administering the drug. Initials may be used after the person's full signature appears at least once on each page of the medication record. Allergies, including allergy to latex, must also be listed;
• A record of self-administered medications, if the patient self-administers, in accordance with the policies and procedures of the hospital's pharmacy and therapeutic committee, or its equivalent;
• Reports of laboratory, radiological, and diagnostic services;
• A discharge summary, which includes the reason for admission, findings, treatment, condition on discharge, medication on discharge, final diagnosis, and, in the case of death, the events leading to death and the cause of death. For cases where the patient is discharged alive within 48 hours of admission and is not transferred to another facility, for normal newborns, and for uncomplicated deliveries, a discharge note may be substituted for the discharge summary. The discharge note includes at least the patient's condition on discharge, medications on discharge, and discharge instructions;
• A report of autopsy, if performed by the hospital, with provisional anatomic diagnoses recorded in the medical record within three days. The complete protocol is included in the medical record within the time specified in hospital policies and procedures; and
• Any adverse incident, including patient injuries.

If the patient is transferred to another health care facility (including a home health agency) on a nonemergency basis, the hospital must create and send to the receiving facility a transfer record reflecting the patient's immediate needs and at least the following information:

• Diagnoses, including history of any serious physical conditions unrelated to the proposed treatment which might require special attention to keep the patient safe;
• Physician orders in effect at the time of discharge and the last time each medication was administered;
• The patient's nursing needs;
• Hazardous behavioral problems;
• Drug and other allergies; and
• A copy of the patient's advance directive, where available.

Medical records shall be completed within 30 days of discharge and retained and preserved in accordance with N.J.S.A. 26:8-5 et seq. Original medical must be kept on hospital premises unless they are under court order or subpoena or in order to safeguard the record in case of a physical plant emergency or natural disaster.

Any consent form for medical treatment that the patient signs shall be printed in an understandable format and the text written in clear, legible, nontechnical language. In the case where someone other than the patient signs the forms, the reason for the patient's not signing it shall be indicated on the face of the form, along with the relationship of the signer to the patient. Recording errors in the medical record shall be corrected by drawing a single line through the incorrect entry. The date of correction and legible signature or initials of the person correcting the error shall be included.

The patient's death shall be documented in the patient's medical record upon death.