N.J. Admin. Code § 8:36-15.6

Current through Register Vol. 56, No. 19, October 7, 2024

Section 8:36-15.6 - Residents' individual records

(a) Each resident's record shall include at least the following:

1. The resident's completed admission application and all records forwarded to the facility;

2. The resident's name, last address, date of birth, name and address of sponsor or interested agency, date of admission, date of discharge (and discharge destination) or death, the name, address and telephone number of physician to be called, and the name and address of nearest relative, guardian, responsible person, or interested agency, together with any other information the resident wishes to have recorded;

3. A copy of the resident's advanced directive, if applicable; and

4. A copy of the resident's general service plan and/or health service plan, if applicable.

(b) All assessments and treatments by health care and service providers shall be entered according to the standards of professional practice. Documentation and/or notes from all health care and service providers shall be entered according to the standards of professional practice.

N.J. Admin. Code § 8:36-15.6