N.J. Admin. Code § 8:111-19.3

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:111-19.3 - Contents of clinical records

(a) The facility shall require, at a minimum, the following to be included in the clinical record:

1. Client identification data, including name, date of admission, address, date of birth, race, religion (optional), gender and the name, address and telephone number of the person(s) to be notified in an emergency;

2. Admission, discharge and other reports required by this chapter as part of the substance abuse client management information system, as well as previous treatment records and correspondence;

3. The client's signed acknowledgment that he or she has been informed of and received a copy of client rights, fee schedule and payment policy;

4. A summary of the admission interview, and a copy of the biopsychosocial assessment;

5. Documentation of the medical history and physical examination signed and dated by the physician for opioid treatment and detoxification clients or the comprehensive health history for clients receiving other residential or outpatient substance abuse services;

6. A client treatment plan signed and dated by medical and clinical personnel as required by this chapter;

7. Clinical notes shall be entered on the day the service is rendered;

8. A log recording the clothing, personal effects, valuables, funds and other property deposited by the client with the facility for safekeeping, signed by the clients, his or her family or legally authorized representative and substantiated by receipts given to the client, his or her family or legally authorized representative;

9. Medical notes for services provided by physicians, nurses and other licensed medical practitioners shall be entered in the client record on the day of service;

10. Documentation of the client's participation in the development of his or her treatment plan, or documentation by a physician or licensed clinician that the client's participation is medically or clinically contraindicated;

11. A record of medications administered, including the name and strength of the drug, date and time of administration, the dosage administered, method of administration, a description of reactions if observed, and signature of the person who administered the drug;

12. A record of self-administered medications, in accordance with the facility's policies and procedures and this chapter;

13. Documentation of the client's allergies in the clinical record on the outside front cover of the client record;

14. The results of laboratory, radiological, diagnostic, and/or screening tests performed;

15. Reports of accidents or incidents required to be reported to the administrator, governing authority, and/or the Department;

16. A record of referrals to other health care and social service providers, including those made to mental health providers;

17. Summaries of consultations;

18. Any signed, written informed consent forms or an explanation of why an informed consent was not obtained from the client;

19. A record of any treatment, drug or service offered by appropriate staff and refused by the client;

20. Record of psychotropic medications or mood altering medications prescribed to the client;

21. Instructions given to the client and/or the client's family for care following discharge;

22. The continuum of care plan; and

23. The continuum of care summary, in accordance with 26:8-5.

N.J. Admin. Code § 8:111-19.3

Amended and recodified from 10:161A-19.3 53 N.J.R. 2208(a), effective 12/20/2021