N.J. Admin. Code § 10:60-2.4

Current through Register Vol. 56, No. 17, September 3, 2024

Section 10:60-2.4 - Clinical records

(a) Clinical records containing pertinent past and current information, recorded according to accepted professional standards, shall be maintained by the home health agency for each beneficiary receiving home health care services. The clinical record shall include, at a minimum, the following:

1. A plan of care as described in 10:60-2.3;

2. Appropriate identifying information;

3. The name, address, and telephone number of beneficiary's physician/practitioner;

4. Clinical notes by nurses, social workers, and special therapists, which shall be written, signed and dated on the day each service is provided;

5. Clinical notes to evaluate a beneficiary's response to service on a regular, periodic basis, which shall be written, signed and dated by each discipline providing services;

6. Summary reports of pertinent factors from the clinical notes of the nurses, social workers, and special therapists providing services, which shall be submitted to the attending physician/practitioner at least every 60 days; and

7. When applicable, transfer of the beneficiary to alternative health care, which shall include transfer of appropriate information from the beneficiary's record.

N.J. Admin. Code § 10:60-2.4

New Rule, R.1994 d.41, effective 1/18/1994.
See: 25 New Jersey Register 2803(a), 26 New Jersey Register 364(c).
Recodified from N.J.A.C. 10:60-1.7 and amended by R.2001 d.14, effective 1/2/2001.
See: 32 New Jersey Register 3940(a), 33 New Jersey Register 66(a).
In (a)1, amended the N.J.A.C. reference; substituted references to beneficiaries for references to recipients throughout the section. Former N.J.A.C. 10:60-2.4, Procedures used as financial controls for CCPED, repealed.

Amended by 54 N.J.R. 1721(a), effective 9/6/2022