N.J. Admin. Code § 8:39-36.1

Current through Register Vol. 56, No. 23, December 2, 2024

Section 8:39-36.1 - Advisory policies and procedures for medical records

(a) The name by which the resident wishes to be called is entered on the cover or first page of the medical record.

(b) There is a comprehensive discharge summary with statistical and narrative information from each service completed for each resident.

(c) The full medical records for all discharged or deceased residents are completed within 15 days.

(d) Telephone orders are countersigned by a physician or advanced practice nurse within 48 hours except for orders for non-prescription drugs or treatments, which are countersigned within seven days.

N.J. Admin. Code § 8:39-36.1