N.J. Admin. Code § 10:58-1.11

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:58-1.11 - Recordkeeping; routine or follow-up visits

(a) In order to document the record for reimbursement purposes, the progress note for routine office visits or follow-up care visits shall include the following:

1. In an office:

i. The purpose of the visit;

ii. Pertinent history obtained;

iii. Pertinent physical findings, including pertinent negative physical findings based on (a)i and ii above;

iv. The procedures, if any, with results;

v. Laboratory, X-ray, EKG, etc., ordered with results; and

vi. The diagnosis(es).

2. In a hospital or nursing facility setting:

i. An update of symptoms;

ii. An update of physical symptoms;

iii. A resume of findings of procedures, if any done;

iv. Pertinent positive and negative findings of lab, X-ray;

v. Additional planned studies, if any, and why; and

vi. Treatment changes, if any.

N.J. Admin. Code § 10:58-1.11

Recodified from N.J.A.C. 10:58-1.10 by R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
Former N.J.A.C. 10:58-1.11, Recordkeeping; hospital inpatient stay, recodified to N.J.A.C. 10:58-1.12.
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 without change.