N.J. Admin. Code § 10:161B-18.3

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:161B-18.3 - Contents of clinical records

(a) The facility shall require the following, at a minimum, to be included in the clinical record:

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

2. Admission, discharge and other reports required by this chapter as part of the substance abuse client management information system, as well as previous treatment records and correspondence;

3. The client's signed acknowledgment that he or she has been informed of and received a copy of client rights;

4. A summary of the admission interview, and a copy of the biopsychosocial assessment;

5. Documentation of the medical history and physical examination signed and dated by the physician for opioid treatment and detoxification clients, or the comprehensive health history for clients receiving other outpatient services;

6. A client treatment plan signed and dated by medical and clinical personnel as required by this chapter;

7. In programs providing IOP and PC services, clinical notes, including progress notes for individual, group, and family counseling sessions as well as psycho-educational groups, shall be documented in each client's record no less than weekly by a summary note for each individual and group session listing the date and topic of all treatment sessions attended, and a narrative of his or her participation and treatment progress. Weekly summary notes shall be based on the compilation of the session notes of all clinicians providing services to the client;

8. In programs providing OP services, clinical notes, including progress notes for individual, group, and family counseling sessions as well as psycho-educational groups, shall be documented in each client's record by contact listing the date and topic of all treatment sessions attended, and a narrative of his or her participation and treatment progress;

9. In programs providing OTP services, clinical notes, including progress notes for individual, group, and family counseling sessions as well as psycho-educational groups, shall be documented in each client's record by contact listing the date and topic of all treatment sessions attended, and a narrative of his or her participation and treatment progress. Medication dispensing requires documentation per contact but does not require a narrative or summary;

10. Medical notes for services provided by physicians, nurses and other licensed medical practitioners shall be entered in the client record on the day of service;

11. Documentation of the client's participation in the development of his or her treatment plan, or documentation by a physician or licensed clinician that the client's participation is medically contraindicated;

12. A record of medications administered, including the name and strength of the drug, date and time of administration, the dosage administered, method of administration, a description of reactions if observed, and signature of the person who administered the drug;

13. A record of self-administered medications, in accordance with the program's policies and procedures;

14. A record of medications dispensed or prescribed for home use;

15. Documentation of the client's allergies in the clinical record and on the outside front cover of the client record;

16. The results of laboratory, radiological, diagnostic, and/or screening tests performed;

17. Reports of accidents;

18. A record of referrals to other health care and social service providers;

19. Summaries of consultations;

20. Any signed, written informed consent forms or an explanation of why an informed consent was not obtained;

21. A record of any treatment, drug, or service offered by appropriate program staff and refused by the client;

22. Instructions given to the client and/or the client's family for care following discharge;

23. The discharge/continuum of care plan; and

24. The discharge/continuum of care summary, in accordance with N.J.S.A. 26:8-5.

N.J. Admin. Code § 10:161B-18.3