N.J. Admin. Code § 10:53A-2.6

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

Section 10:53A-2.6 - Recordkeeping

(a) The medical record of the hospice beneficiary maintained by the hospice shall be complete and accurate and reflect the services provided. The medical record shall include, at a minimum, the following information:

1. Identification information;

2. Certification/recertification documents;

3. Informed consent documents;

4. Election forms;

5. Hospice eligibility forms;

6. Pertinent medical history and physical examination data;

7. Test results;

8. Initial and subsequent assessments;

9. Plan of care and updates; and

10. Complete documentation of all services and events (including evaluations, treatments, progress notes, etc.).

(b) All medical records shall be signed and dated by the professional staff person providing the service.

(c) The medical record shall be maintained and made available, as necessary, to the Division of Medical Assistance and Health Services or its agent for audit and review purposes in accordance with State law (see N.J.S.A. 30:4D-12 and (N.J.A.C. 10:49-13.1).

N.J. Admin. Code § 10:53A-2.6

Amended by R.2003 d.320, effective 8/4/2003.
See: 34 New Jersey Register 2899(a), 35 New Jersey Register 3568(a).
In (a), in main paragraph substituted "beneficiary" for "recipient".