N.J. Admin. Code § 10:58-1.14

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

Section 10:58-1.14 - Recordkeeping; home visit or house call

(a) The record and documentation of a home visit or house call shall become part of the office progress notes and shall include, as appropriate, the following information:

1. The purpose of the visit;

2. The pertinent history obtained;

3. Pertinent physical findings, including pertinent negative physical findings based on (a)1 and 2 above;

4. The procedures, if any performed, with results;

5. Laboratory, X-ray, ECG, etc., ordered with results; and

6. The diagnosis(es) plus treatment plan status relative to present or pre-existing illness(es) plus pertinent recommendations and actions.

N.J. Admin. Code § 10:58-1.14

Recodified from N.J.A.C. 10:58-1.13 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).
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.