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New Jersey PT Documentation
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:
What are the physical therapist’s documentation responsibilities?
A PT must prepare and maintain for each patient a contemporaneous, permanent patient record that accurately reflects the patient contact with the PT whether in an office, hospital or other treatment, evaluation or consultation setting.
Exception to the documentation requirements
When a PT provides training in techniques for the prevention of injury, impairment, movement-related functional limitation or dysfunction that is not specifically designed for an individual, the PT shall not be required to maintain records.
A PT that provides such training shall maintain records that include:
How long do the records need to be retained?
Patient records must 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 must provide one 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.
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 PT shall:
Charging the patient for copies
PTs 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.
N.J.A.C. § 13:39A-3.1
N.J.A.C. § 13:39A-3.3