N.J. Admin. Code § 10:58-1.15

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

Section 10:58-1.15 - Recordkeeping requirements for birth center services

(a) Medical records maintained by a birth center for the maternity services shall include, but not be limited to:

1. Patient identification;

2. An initial medical history, results of physical examination, and diagnosis;

3. Progress notes for each visit, which shall include interim history, physical findings, and disposition;

4. Reports of laboratory and other diagnostic studies, and consultation;

5. Any allergies and abnormal drug reactions;

6. A report of the delivery process;

7. The status and condition of the newborn;

8. Documentation of properly executed informed consent of each woman enrolling in a birth center for treatment; and

9. A discharge diagnosis.

N.J. Admin. Code § 10:58-1.15

New Rule, R.1998 d.209, effective 5/4/1998.
See: 30 N.J.R. 57(a), 30 N.J.R. 1613(a).