N.J. Admin. Code § 8:43D-12.1

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

Section 8:43D-12.1 - Residents' individual records

(a) Each resident's record shall include at least the following:

1. The resident's completed admission application and all records forwarded to the facility;

2. The resident's name, last address and date of birth; the name and address of sponsor or community agency; the date of admission; the date of discharge (including discharge destination) or death; the name, address, and telephone number of the physician to be called in either set of circumstances; and the name and address of nearest relative, guardian, designated responsible person(s), or community agency, together with any other information the resident wishes to have recorded;

3. A copy of the resident's interdisciplinary care plan, if applicable;

4. All assessments and treatments by health care and service providers shall be entered according to the standards of professional practice. Documentation and/or notes from all health care and service providers shall be entered according to the standards of professional practice and be accessible at the facility; and

5. Services provided by facility staff or by personnel on a contractual basis apart from health care treatment shall be entered into the resident's record.

N.J. Admin. Code § 8:43D-12.1

Amended by 48 N.J.R. 2336(a), effective 11/7/2016