N.J. Admin. Code § 8:43F-15.3

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

Section 8:43F-15.3 - Contents of medical records

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

1. Participant identification data, including name, date of admission, address, date of birth, race, religion (optional), sex, referral source, payment plan, marital status, and the name, address, and telephone number of the person(s) to be notified in an emergency, and travel directions to the participant's home;

2. The participant's signed acknowledgment that the participant or the participant's legally authorized representative has been informed of, and given a copy of, participant's rights;

3. An assessment of the participant's home environment;

4. A summary of the admission interview;

5. Documentation of the medical history and physical examination signed and dated by the physician, advanced practice nurse or physician assistant;

6. Assessments developed by each service providing care to the participant;

7. A plan of care;

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

9. Progress notes;

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

11. A record of self-administered medications, if the participant self-administers medications;

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

13. Documentation of dental, laboratory, and radiological services provided;

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

15. Documentation of consultations;

16. Any signed written informed consent forms;

17. Documentation regarding an advance directive, if applicable;

18. A record of any treatment, medication, or service offered by personnel of the facility and refused by the participant;

19. All orders for treatment, medication, and diets, signed by a physician, advanced practice nurse or physician assistant. Physician, advanced practice nurse or physician assistant orders for speech-language pathology, physical therapy, and occupational therapy services shall include specific modalities and the frequency of treatment;

20. An attendance record listing all of the days on which the participant was in the facility;

21. A current photograph of the participant; and

22. The discharge summary, in accordance with 26:8-5 et seq.

N.J. Admin. Code § 8:43F-15.3