N.J. Admin. Code § 8:43G-16.2

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

Section 8:43G-16.2 - Medical staff policies and procedures

(a) The medical staff shall have written policies, procedures, and bylaws that are reviewed at least once every three years; revised more frequently as needed, and implemented. They shall include at least:

1. Policies and procedures addressing the requirements for obtaining written informed consent from patients;

2. Requirements for the completeness and timing of the patient history and physical examination, including a listing of the minimum contents to be included in the medical record;

3. The minimum content of physician orders;

4. Specifications for verbal orders, including who may give verbal orders, who may receive them, and how soon they must be verified or countersigned in writing;

5. If applicable, policies and procedures related to the prescribing or ordering of medications or devices by certified nurse practitioners/clinical nurse specialists in accordance with New Jersey State Board of Nursing rules at N.J.A.C. 13:37-7; and

6. If applicable, the scope of practice, supervision, and record keeping requirements of licensed physician assistants in accordance with New Jersey State Board of Medical Examiners rules at N.J.A.C. 13:35-2B.

(b) All physician orders for medication, treatment and restraints shall be in writing. All orders for restraints shall be made in accordance with requirements at 8:43G-18.4(c) through (e) and (h).

(c) The medical staff shall have a means to assess individual patient's competence to consent to treatment in conformance with current law. Measurement of patient competence may include such skills as ability to understand their medical condition and the consequences of procedures and treatments, and to communicate a choice. The hospital and physician shall follow the procedures for appointment of a special medical guardian where required in accordance with the Civil Practice Rules at 4:83-12.

(d) Each time the attending physician visits the patient, the physician shall enter a note into the medical record describing the findings about the patient's condition. If issues have been raised in the record by other disciplines, this note shall respond to them.

(e) The hospital shall comply with the New Jersey State Board of Medical Examiners rules concerning the registration and permit requirements for graduate medical education programs and practice, 13:35-1.5.

(f) The hospital shall require that all prescriptions and orders issued by registered first-year residents in the inpatient setting be countersigned by a licensed physician or permit holder (a person authorized in the State of New Jersey to engage in the practice of medicine in the second year of a graduate medical education program or beyond).

N.J. Admin. Code § 8:43G-16.2

Amended by R.1992 d.72, effective 2/18/1992.
See: 23 N.J.R. 2590(a), 24 N.J.R. 590(a).
Reference changed at (b).
Amended by R.1995 d.124, effective 3/20/1995.
See: 26 N.J.R. 4537(a), 27 N.J.R. 1290(a).
Amended by R.1999 d.436, effective 12/20/1999.
See: 31 N.J.R. 367(a), 31 N.J.R. 614(a), 31 N.J.R. 4293(c).
In (a), substituted "at least once every three years; revised more frequently" for "annually, revised" in the introductory paragraph.
Amended by R.2011 d.055, effective 2/22/2011.
See: 42 N.J.R. 1774(a), 42 N.J.R. 2561(a), 43 N.J.R. 401(b).
In (b), deleted a comma following "treatment", and substituted "(h)" for "(i)".