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:
- dates of all treatments
- patient complaint and medical history
- findings on examination, progress notes, orders for tests, consultation and the results
- diagnosis, medical impressions
- treatment ordered, including specific dosage, quantities, strengths, refills and recommended follow-ups
- documentation when reasonable efforts by the physician to report necessary test results to patient were unsuccessful
- 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.