N.J. Admin. Code § 10:66-5.4

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

Section 10:66-5.4 - Medical records

(a) In addition to the requirements set forth at 42 CFR 416.47, medical records in an ASC shall include, but not be limited to:

1. Patient identification;

2. Significant medical history and results of physical examination;

3. Pre-operative diagnostic studies (entered before surgery), if performed;

4. Findings and techniques of the operation, including a pathologist's report on all tissues removed during surgery, except those exempted by the governing body;

5. Any allergies and abnormal drug reactions;

6. Entries related to anesthesia administration;

7. Documentation of properly executed informed consent; and

8. Discharge diagnosis.

N.J. Admin. Code § 10:66-5.4

Amended by R.1998 d.577, effective 12/7/1998.
See: 30 New Jersey Register 3434(a), 30 New Jersey Register 4225(b).