N.J. Admin. Code § 8:43A-13.3

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

Section 8:43A-13.3 - Contents of medical records

(a) The complete medical record shall include, but not be limited to, the following:

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

2. The patient's complaint or purpose of the visit;

3. The diagnosis or medical impressions;

4. Orders for laboratory, radiological, diagnostic, and/or screening tests and their results;

5. All orders for treatment, medication, and diets, signed by the prescriber;

6. Documentation of the medical history and physical examination, if performed, signed and dated by the examiner;

7. Patient assessments developed by each service providing care to the patient;

8. A patient plan of care, in accordance with the facility's policies and procedures;

9. Clinical notes, which shall be entered on the day service is rendered;

10. A medication sheet indicating at least the name, date, dosage, and duration of all medications prescribed;

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

12. Documentation of drug allergies in the medical record and on its outside front cover and documentation of other allergies in the medical record;

13. An immunization record, in accordance with the facility's policies and procedures;

14. A record of referrals to or from other health care providers;

15. Documentation of any consultations ordered or provided;

16. Documentation that informed consent was obtained for any procedure or treatment provided which is specified in the facility's policies and procedures as requiring informed consent;

17. Documentation regarding an advance directive, if applicable;

18. The patient's signed acknowledgement that the patient has been informed of patient rights, either verbally or through written copy, and has been offered a copy;

19. Instructions given to the patient and/or family for follow-up care;

20. A record of any treatment, drug, or service offered by personnel of the facility and refused by the patient;

21. The discharge plan, where applicable, and a discharge summary sheet containing the patient's name, address, dates of admission and discharge, and a summary of the treatment and medication rendered during the patient's stay; and

22. Any authorizations granted by the patient for release of the patient's medical record.

N.J. Admin. Code § 8:43A-13.3