N.J. Admin. Code § 10:37-6.74

Current through Register Vol. 56, No. 19, October 7, 2024

Section 10:37-6.74 - Required contents for all records

(a) The client record shall contain the following information:

1. The identifying and other data indicated on the Division's Unified Services Transaction Form for enrolled and terminated clients.

2. Comprehensive assessment and evaluation of client needs, including level of functioning and a natural support resource inventory for all clients.

3. A social, psychological, and/or a psychiatric mental status evaluation, as needed.

4. Individual service plan with updated revisions.

5. A copy of any advance directive for mental health care executed by the patient, and a note that indicates the whereabouts of any copies of the directive, including whether the advance directive has been registered with DMHS, if known, or if no advance directive has been executed, a note documenting the actions taken by the staff of the agency to provide the client with the opportunity to execute an advance directive.

6. Clinical diagnosis based on the clinical evaluation of the client.

7. Client and/or mental health care representative consent for service initiation, evaluation, or research as permitted or required by law, and appropriate authorizations for record sharing.

8. Utilization Review Committee meeting notes which include the attendees, recommendations made, and actions taken.

9. Medications.

10. Laboratory or other diagnostic procedures.

11. Unusual incidents, occurrences such as:

i. Treatment complications;

ii. Accidents or injuries;

iii. Morbidity;

iv. Death of a client; and

v. Procedures placing the client at risk or causing pain/harm.

12. Correspondence related to the client and signed, dated notations of relevant contacts regarding the client's service/treatment.

13. Discharge or transfer summary in addition to the discharge plan which shall also be developed with the client and completed within 30 days of last service.

14. The record shall contain documentation of procedures that place clients at risk or in pain including, but not limited to restraint, seclusion; and/or behavior modification using painful stimuli. Such records shall document the justification for the use of the procedure, attempts of staff to provide alternatives, the specific procedures employed, the required authorization, and the measures taken to protect the client's safety and rights.

15. All entries in the record shall be legibly signed and dated.

N.J. Admin. Code § 10:37-6.74

Amended by R.2007 d.187, effective 6/18/2007.
See: 38 N.J.R. 3407(a), 39 N.J.R. 2346(a).
Rewrote (a).