7 Things New Jersey Physicians Must Know About Patient Records

The fact that physicians must prepare and maintain records is hardly news to anyone. It may have, however, been a while since a physician last reviewed the requirements for patient documentation in New Jersey that are imposed by the Board of Medical Examiners (BME).

Here is a quick refresher course. To the extent possible, BME requires that medical charts must reflect:

  1. dates of all treatments
  2. patient complaint and medical history
  3. findings on examination, progress notes, orders for tests, consultation and the results
  4. diagnosis, medical impressions
  5. treatment ordered, including specific dosage, quantities, strengths, refills and recommended follow-ups
  6. documentation when reasonable efforts by the physician to report necessary test results to patient were unsuccessful
  7. documentation of the existence of any advance directive for health care for an adult or emancipated minor and any associated pertinent information

Records must be maintained for a period of 7 years from the date of the most recent entry.

Physicians should also remember that if planning to charge for copying and preparation of medical charts and x-rays, it is important to check the appropriate regulations to avoid improper conduct.