N.J. Admin. Code § 8:42-7.4

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

Section 8:42-7.4 - Nursing entries in the medical/health record

(a) In accordance with written job descriptions and with this chapter, nursing personnel shall document in the patient's medical/health record:

1. The nursing plan of care in accordance with the agency's policies and procedures;

2. Clinical notes and progress notes; and

3. A record of medications administered. After each administration of medication, the following shall be documented by the nurse who administered the drug:

i. Name and strength of the drug;

ii. Date and time of administration;

iii. Dosage administered;

iv. Method of administration; and

v. Signature of the licensed nurse who administered the drug.

N.J. Admin. Code § 8:42-7.4

Amended by 48 N.J.R. 1445(a), effective 7/18/2016