N.J. Admin. Code § 8:43A-13.4

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:43A-13.4 - Requirements for entries

(a) All orders for patient care shall be prescribed in writing and signed and dated by the prescriber, in accordance with the laws of the State of New Jersey. All orders, including verbal orders, shall be verified or countersigned in writing within seven days.

(b) All entries in the medical record shall be typewritten or written legibly in ink, dated, and signed by the person entering them, or, if a computerized medical records system is used, authenticated.

1. If computer-generated orders with a physician's electronic signature are used, the facility shall develop a procedure to assure the confidentiality of each electronic signature and to prohibit the improper or unauthorized use of any computer-generated signature.

2. If a facsimile communications system (FAX) is used, entries into the medical record shall be in accordance with the following procedures:

i. The physician shall sign the original order, history and/or examination at an off-site location;

ii. The original shall be transmitted by FAX system to the facility for inclusion into the medical record;

iii. The physician shall submit the original for inclusion into the medical record within seven days, unless a plain-paper laser facsimile process was used; and

iv. The copy transmitted by FAX system shall be replaced by the original, unless a plain-paper laser facsimile process was used.

(c) The medical record shall be completed within the time frame specified in the medical records policies and procedures, which shall be no longer than 30 days from the last treatment or discharge.

(d) The medical record shall be available to the facility's health care practitioners involved in the patient's care at all times during the hours of operation.

N.J. Admin. Code § 8:43A-13.4