N.J. Admin. Code § 8:43A-24.14

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

Section 8:43A-24.14 - Medical records

(a) In addition to compliance with the requirements of N.J.A.C. 8:43A-13, the facility shall assure the following:

1. An area for medical records storage, which is separate from all patient treatment areas, shall be provided. The medical records area shall have adequate space for reviewing, dictating, sorting, or recording records. If electronic imaging devices are employed (that is, microfilm or optical disc), the medical records area shall have adequate space for transcribing records in electronic format. The facility shall store the active medical record of each patient currently treated by the facility on site.

2. Signature stamps are not used to authenticate medical record entries.

3. Each medical record shall include:

i. A problem list, including access surgeries for dialysis and prior hospitalizations;

ii. A transfusion record;

iii. A record of creation and revision of access for dialysis; and

iv. Evidence of patient education.

4. A patient's medical history and physical examination shall be completed within 30 days before or two weeks after initial treatment at the facility. For physical examinations performed prior to admission to the renal facility, the admitting physician, nurse practitioner, or physician assistant shall review the physical examination findings prior to the patient's first treatment at the renal dialysis facility and shall indicate on the physical exam form any significant changes in the patient's medical condition that occurred since the physical examination was performed.

i. Prior to the first treatment in the facility, the physician shall inform the nurse functioning in the charge role of at least the patient's diagnoses, medications, hepatitis status, allergies, and dialysis prescription. The clinical record shall include this data. No dialysis shall be initiated until this requirement is met.

5. Prior to providing dialysis treatment of a transient patient, a facility shall obtain and include, at a minimum:

i. Orders for treatment in the facility;

ii. A list of the patient's current medications and any known patient allergies;

iii. Laboratory reports performed no later than one month prior to treatment at the facility, including screening for hepatitis B status;

iv. The most current patient care plan; and

v. The most current treatment records from the referring facility.

6. At the completion of treatment at the transient facility, records of care and treatment are provided to the referring facility.

N.J. Admin. Code § 8:43A-24.14