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New Jersey Physical Therapy Documentation
What are a therapist’s documentation responsibilities?
A licensed physical therapist shall prepare and maintain for each patient a contemporaneous, permanent patient record that accurately reflects the patient contact with the licensed physical therapist whether in an office, hospital or other treatment, evaluation or consultation setting.
What must be included in the patient record?
The patient record shall include, in addition to personal identifying information, consents and disclosures, at least the following information:
Patient records shall be maintained for at least seven (7) years from the date of the last entry, unless another agency or entity requires the records to be kept for a longer time.
Release of Patient Records
The PT shall provide one (1) copy of the patient's record of physical therapy treatment within fifteen (15) days of a written request by the patient or any person whom the patient has designated to receive that record.
The PT may require a record request to 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 miscellaneous costs associated with retrieval of the record.) If the patient requests a summary in lieu of the actual record, the charge for the summary shall not exceed the cost that would be charged for the actual record.
If the patient or a subsequent treating health care professional is unable to read the treatment record, either because it is illegible or prepared in a language other than English, the licensed physical therapist shall provide a transcription at no cost to the patient or the person requesting the record.
Release to a third-party
Where the patient has requested the release of a professional treatment record or a portion thereof to a specified individual or entity, in order to protect the confidentiality of the records, the licensed physical therapist shall:
N.J.A.C. § 13:39A-3.1