N.J. Admin. Code § 10:58-1.13

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

Section 10:58-1.13 - Recordkeeping; preventive medicine services; annual health maintenance examination

(a) For individuals under 21 years of age, the following shall be performed and documented in the beneficiary's record:

1. A history (complete initial for new patient, interval for established patient) including past medical history, family history, social history, and systemic review;

2. A developmental and nutritional assessment;

3. A complete, unclothed, physical examination to also include the following:

i. Measurements, including: height and weight; head circumference to 25 months; blood pressure for children age three years or older; and

ii. Vision and hearing screening;

4. An assessment and administration of immunizations appropriate for age and need, as determined by medical practice and professional medical judgment, in accordance with 42 U.S.C. § 1396s and N.J.A.C. 10:58-3;

5. Provisions for further diagnosis, treatment and follow-up, by referral if necessary, of all correctable abnormalities uncovered or suspected;

6. Referral to a dentist for children age three years or older;

7. Laboratory procedures performed or referred if medically necessary. Recommendations are:

i. Hemoglobin/Hematocrit: 10 to 12 years;

ii. Urinalysis: 13 to 18 years;

iii. Tuberculin test (Mantoux) annually;

iv. Lead screening using blood level determinations shall be performed between six and 12 months, at two years of age, and annually up to six years of age. At all other visits, screening shall consist of verbal risk assessment and blood lead level test, as indicated; and

v. Other appropriate screening procedures, if medically necessary, (for example: blood cholesterol, test for ova and parasites, STD);

8. Health education and anticipatory guidance; and

9. An offer of social service assistance; and, if requested, referral to a county board of social services (CBOSS).

N.J. Admin. Code § 10:58-1.13

Recodified from N.J.A.C. 10:58-1.12 by R.1998 d.154, effective 2/27/1998 (operative March 1, 1998; to expire August 31, 1998).
See: 30 N.J.R. 1060(a).
Former N.J.A.C. 10:58-1.13, Recordkeeping; home visit or house call, recodified to N.J.A.C. 10:58-1.14.
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 N.J.R. 1060(a), 30 N.J.R. 3519(a).
Readopted the provisions of R.1998 d.154 without change.
Amended by R.2001 d.204, effective 6/18/2001.
See: 33 N.J.R. 1160(a), 33 N.J.R. 2188(a).
In (a), substituted "beneficiary's" for "recipient's" in the introductory paragraph and in 9, substituted "board of social services (CBOSS)" for "welfare agency".