MEDICAL RECORDS                                                                                           35-02-010



The Division of Veterans Healthcare Services (DVHS) requires each of the New Jersey Veterans Memorial Homes (VMH) to ensure that all residents are assured of the confidential treatment of their Medical Record in accordance with New Jersey Department of Health and Senior Services and U.S. Department of Veterans Administration regulatory requirements regarding the release of Protected Healthcare Information (PHI); and that residents are able to obtain a copy of their Medical Record upon request.


This policy and procedure serves to ensure that each of the New Jersey Veterans Memorial Homes implements a process that ensures each and every resident is assured confidential treatment of his or her Medical Records, and is afforded the ability to approve or deny the release and/or reproduction of records.   


The following steps will be followed when there is a request for release of medical information.

  1. The resident and/or the resident’s legally authorized representative must sign a Medical Information Release Form, unless the information is being sent to a facility where the resident will be permanently transferred.

  2. Records shall be copied according to Photocopying Procedures for Medical Records.

  3. All medical information being release or requested must be documented in the Release of Medical Information Log Book.

  4. A copy of the Medical Information Release Form shall be maintained in the resident's Medical Record.

  5. Access to Medical Records will be by appointment only, free of charge. 

  6. Access to the Medical Record shall be limited only to the extent necessary to protect the resident. A verbal explanation for any denial of access shall be given to the resident or the resident’s legally authorized representative by the physician or advanced practice nurse, and there shall be documentation of this in the medical record.  In the event that direct access to a copy of the medical record by the resident is medically contraindicated (as documented by the physician or advanced practice nurse in the resident’ medical record), the medical record shall be made available to a legally authorized representative of the resident.

  7. The following list of steps should be followed when photocopying Medical Records:

    1. Whenever possible, authorized internal users will be encouraged to use the original health record rather than a facsimile.

    2. The Medical Record Supervisor or designee will authorize photocopying of Medical Records.

    3. Competent residents and/or their legally authorized representative must sign a Medical Information Release Form when applicable.

    4. Photocopies will be processed within 48 hours of written request (two (2) business days, excluding weekends and holidays).  Should a delay occur, written notification regarding same and expected completion date must be sent to the resident and/or their legally authorized representative.

    5. Only specifically requested forms shall be copied and sent to the requestor, unless the information is being sent to a facility where the resident is being permanently transferred.  In that case, an abstract or pertinent portion of the record that summarizes important aspects of resident care is to be copied and sent to the requestor.  The following list of items constitutes an abstract:

      Admission Record                                             Social Service History/Progress Notes
      Departmental Discharge Summaries                Dietary Progress Notes
      Departmental Initial Assessments                   Consultant Reports
      History and Physicals                                       Activities Progress Notes
      Medical Plan of Care                                        Therapy Progress Notes (PT, OT, etc.)
      Physician Orders                                              Medication and Treatment Records
      Physician Progress Notes                                Lab, X-ray, EKG slips/reports
      Nursing Monthly Summaries       


  8. When photocopies or other reproductions of Medical Records are provided to authorized external users, a statement addressing the following will accompany these copies:

    1. Prohibiting use of the information for any other than the stated purpose.

    2. Prohibiting disclosure by recipient to any other party.

    3. The information enclosed is privileged and its confidentiality must be maintained.

  9. The VMH shall encourage the provision of abstracts or summaries of medical records. However, the resident or their legally authorized representative has a right to receive a full or certified copy of the medical record.

  10. The resident shall have the right to attach a brief comment or statement to his or her medical record after completion of the medical record.

  11. The following outlines the fees charged for the photocopying of all documents:  

                           First 100 pages                         = $ 1.00 per page
                           From the 101st page to end      = $ 0.25 per page
                           There is a Maximum Charge of $200.00 for the entire medical record.
                           (  N.J.A.C. § 13:35-6.5(c)(4) )

  12. Copying fees shall not exceed $1.00 per page, or $100.00 per record for the first 100 pages. For records which contain more than 100 pages, a copying fee of no more than $0.25 per page may be charged for pages in excess of the first 100 pages, up to a maximum of $200.00 for the entire record

  13. A search fee of no more than $10.00 per resident per request may be charged to search the Medical Records Department for a specific Medical Record.

  14. A postage charge for the actual costs for mailing a Medical Record may be charged. No charges other than those stated may be charged.

  15. In cases where the resident does not have the ability to pay the cost of copying his/her medical records, a discussion shall be held between the CEO, the resident and/or family, and the Medical Records Supervisor to determine the appropriate course of action.


Revised:   July 2007
Revised:   April 2010
Revised:   August 2011