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NEW JERSEY REGISTER
VOLUME 40, ISSUE 11
ISSUE DATE: JUNE 2, 2008
RULE ADOPTIONS
LAW AND PUBLIC SAFETY
DIVISION OF CONSUMER AFFAIRS
STATE BOARD OF VETERINARY MEDICAL EXAMINERS

 

Adopted Amendment:  N.J.A.C. 13:44-4.9

Patient Records

Proposed: December 3, 2007 at 39 N.J.R. 5054(a).
Adopted: March 26, 2008 by the State Board of Veterinary Medical Examiners, Mark Logan, VMD, President.
Filed: May 2, 2008 as R.2008 d.140, with substantive changes not requiring additional public notice and comment (see  N.J.A.C. 1:30-3.6).
Authority: N.J.S.A. 45:16-3.
Effective Date: June 2, 2008.
Expiration Date: January 7, 2010.

Federal Standards Statement

A Federal standards analysis is not required because there are no applicable Federal laws or standards.

Full text of the adoption follows (additions to the proposal indicated in boldface with asterisks *thus*; deletions from the proposal indicated in brackets with asterisks *[thus]*):

13:44-4.9  Patient records

(a) A licensee shall maintain a separate patient record for each animal, herd or flock. All patient records shall accurately reflect the treatment or services rendered. Such records shall include at least the following information:

1.-9. (No change.)

10. The name, initials or other identifying information to indicate the identity of the licensee or agent making the entry in the patient record and the date on which the entry is made; and

11. (No change.)

(b) A licensed veterinarian shall keep records confidential, unless:

1. The licensed veterinarian is required by law to release the records;

2. The Board requests the records;

3. The client, at the time services were rendered by the licensed veterinarian, authorizes the licensed veterinarian to release the records; or

4. It becomes necessary to release information in the records in order to protect the health of a person, the animal that is the subject of the records or another animal.

(c) A licensee may require that a record request 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 costs associated with retrieval of the record.

(d) A licensee shall only release diagnostic imaging, such as a radiograph, pursuant to (b) above. A licensee who obtains a copy of diagnostic imaging may charge a fee that covers the cost of obtaining the copy. A licensee who releases diagnostic imaging shall keep, as part of his or her records:

1. A copy or original of the diagnostic imaging;

2. A release form signed by the individual to whom an original diagnostic imaging is released, indicating that he or she has taken the diagnostic imaging and will return the diagnostic imaging to the licensee; or

3. A certified radiologist's report on the diagnostic imaging.

(e) All records and radiographs on patients shall be retained for a period of five years from the date of the patient's last visit except as provided in (h) or (i) below. Where the records reflect the decease of the patient, all written records and radiographs shall be retained for a period of three years from the last date of entry.

(f) Copies of a licensee's record or a summary report of such record and copies of all pertinent objective data and papers pertaining to a given patient, along with a key to any codes, abbreviations and non-English words appearing on such record, data or papers, shall be furnished to the patient's owner, a designated representative or a designated veterinarian within 10 business days of a written request by the owner or duly authorized representative. A licensee may charge a fee pursuant to (c) above for providing copies of records.

(g) When a patient's life or health is in danger, a licensee shall release information pertinent to the critical care of the patient to the patient's owner, a representative designated by the owner or a veterinarian designated by the owner, immediately upon receiving a request for the information.

(h) (No change in text.)

(i) Whenever a veterinary practice is to be closed due to the retirement or death of the veterinarian in charge, the following shall apply:

1. (No change.)

2. If the medical records are not to be transferred to another veterinary practice, the retiring licensee or the executor or administrator of the licensee's estate shall, prior to disposing of any records*[, notify every owner of a patient that has been treated or examined by the licensee over the past five years. Such notification]* *and within a reasonable period of time, publicize notice of closing of the veterinary practice. The notice of closing shall be published in a daily newspaper with circulation in the county in which the veterinary practice is located, on two occasions, 15 days apart. The notice* shall advise the public of the licensee's retirement or death; shall indicate that the medical records will be available to the client for a period of 60 days subsequent to the *[date of the notification]* *second publication*; and shall include the name, address and telephone number of the person to contact to obtain the medical records.

3. If the medical records are to be transferred to another veterinary practice, the retiring licensee or the executor or administrator of the licensee's estate may transfer the medical records provided that he or she shall, prior to the transfer, *[shall notify every owner of a patient that has been treated or examined by the licensee over the past five years. Such notification]* *publish notice of closing of the veterinary practice. Such notice shall be published in a daily newspaper with circulation in the county in which the veterinary practice is located, on two occasions, 15 days apart. The notice* shall advise the public of the licensee's retirement or death and indicate the name, address and telephone number of the veterinary practice to which the records will be transferred.


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