SENATE, No. 2097
STATE OF NEW JERSEY
INTRODUCED MAY 22, 1997
By Senator LYNCH
A n Act concerning professional treatment records and supplementing Title 45 of the Revised Statutes.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. a. Except as provided in section 1 of P.L.1968, c.230 (C.9:17A-4), no later than 30 days from receipt of a request from a patient or a patient's authorized representative, a physician, podiatrist, chiropractor or optometrist shall provide, without charge, a copy of the professional treatment record pursuant to subsection b. of this section, to the patient or the patient's authorized representative, as appropriate, unless the health care professional states in writing that access by the patient is not medically advisable.
b. The professional treatment record to be provided to a patient or a patient's authorized representative pursuant to this section shall include, to the extent applicable, the dates of all treatment, patient complaint, history, radiological film, findings on appropriate examination of the patient, progress notes, diagnosis or medical impression, prognosis, an order for a test or consultation and the health care professional's interpretation of the results thereof, treatment or medication ordered, treatment options, the identity of the treating health care professional in cases where more than one health care professional practices, and documentation of unsuccessful efforts made to communicate test results. A health care professional may provide a summary of any handwritten notes contained in the record.
2. a. Except as provided in section 1 of P.L.1968, c.230 (C.9:17A-4), no later than 30 days from receipt of a request from a client or a client's authorized representative, a licensed clinical social worker, a licensed social worker or a licensed practicing psychologist shall provide, without charge, a copy of the client's professional treatment record pursuant to subsection b. of this section, to the client or the client's authorized representative, as appropriate, unless the professional states in writing that access by the client would adversely affect the client's health or welfare.
b. The professional treatment record to be provided to a client or a client's authorized representative, as appropriate, pursuant to this section shall include, to the extent applicable, the dates of all treatment, the client's complaint, history, findings on appropriate examination of the client, social work assessment, progress notes, diagnostic impression, prognosis, an order for a test or consultation and the professional's interpretation of the results thereof, treatment ordered, treatment options, and the identity of each provider of treatment, evaluation or consultation, and supervisor, if any. A licensed social worker, licensed clinical social worker or licensed practicing psychologist may provide a summary of any handwritten notes or treatment session notes contained in the record.
3. This act shall take effect immediately.
STATEMENT
This bill allows a patient or a patient's authorized representative to obtain a copy of the patient's professional treatment record, without charge. Similarly, the bill allows a client or a client's authorized representative, to obtain a copy of the client's professional treatment record from a licensed social worker, licensed clinical social worker or a licensed clinical psychologist, without charge.
Under the provisions of the bill, no later than 30 days from receipt of a request from a patient or a patient's authorized representative, a physician, podiatrist, chiropractor or optometrist must provide, without charge, a copy of the professional treatment record to the patient or the patient's authorized representative, as appropriate, unless the health care professional states in writing that access by the patient is not medically advisable.
Likewise, no later than 30 days from receipt of a request from a client or a client's authorized representative a licensed social worker, licensed clinical social worker or a licensed clinical psychologist must provide, without charge, a copy of the professional treatment record, unless the social worker or psychologist states in writing that access by the client would adversely affect the client's health or welfare.
With respect to physicians, podiatrists, chiropractors or optometrists, the professional treatment record shall include, to the extent applicable, the dates of all treatment, the patient complaint, history, radiological film, findings on appropriate examination of the patient, progress notes, diagnosis or medical impression, prognosis, an order for a test or consultation and the health care professional's interpretation of the results thereof, treatment or medication ordered, treatment options, the identity of the treating health care professional in cases where more than one health care professional practices, and documentation of unsuccessful efforts made to communicate test results.
The professional treatment record for licensed social workers, licensed clinical social workers and licensed clinical psychologists shall include, to the extent applicable, the dates of all treatment, the client's complaint, history, findings on appropriate examination of the client, social work assessment, progress notes, diagnostic impression, prognosis, an order for a test or consultation and the professional's interpretation of the results thereof, treatment ordered, treatment options, and the identity of each provider of treatment, evaluation or consultation, and supervisor, if any.
In the case of handwritten notes, the bill allows a physician, podiatrist, chiropractor or optometrist to provide a summary of any handwritten notes contained in the record. A licensed social worker, licensed clinical social worker or licensed practicing psychologist also may provide a summary of any handwritten notes or treatment session notes contained in the record.
Allows medical patients and clients of social workers and psychologists to access records without charge.