N.J. Admin. Code § 8:43G-16.6

Current through Register Vol. 56, No. 23, December 2, 2024

Section 8:43G-16.6 - Medical staff patient services

(a) Each patient shall have an attending physician who has overall responsibility for the patient's care in the hospital.

(b) Each patient admitted to the hospital shall have a medical history and physical examination that includes a provisional diagnosis performed by a clinical practitioner within 30 days before a hospital or outpatient surgery admission or within 48 hours after admission.

1. If the history and physical were performed earlier than seven days before admission, the patient's medical history and physical examination record completed pursuant to (b) above shall be included in the medical record together with the following, subject to the timeline established in (b)2 below with respect to outpatient surgery patients:

i. A written assessment performed by the attending physician, advanced practice nurse or physician assistant no earlier than seven days before and no later than 48 hours after the patient's admission that includes a physical examination of the patient to update any components of the patient's medical status that may have changed since the prior history and physical, to address any areas as to which more current data are needed and to confirm that the necessity of the procedure or care for which the patient was admitted is still present and the history and physical are still current; and

ii. Regardless of whether there were any changes in the patient's status noted in the assessment performed pursuant to (b)1i above, an update note written by the attending physician, advanced practice nurse or physician assistant no earlier than seven days before and no later than 48 hours after the patient's admission addressing the patient's current status and any changes thereto, which note shall be on or attached to the history and physical performed pursuant to (b) above; and

2. The history and physical, and all updates and assessments, shall be included in the patient's medical record, except in emergency situations, within 48 hours after a hospital admission or, for an outpatient, prior to surgery.

(c) When there is a clinical consultant, he or she shall issue a report that states at least the assessment mechanisms used, findings, and opinion. This report shall be included in the medical record.

(d) The reason or reasons for requesting a clinical consultation shall be specified in the patient's medical record by the attending physician. The consultant shall provide consultation in accordance with the privileges accorded him or her by the hospital.

(e) Medical care shall be provided to all patients, regardless of their ability to pay.

(f) Every acute care patient shall receive a visit by a clinical practitioner every day unless there is a clinical basis to justify the patient not receiving such a visit that is documented in the medical record by the practitioner. In all cases a patient shall receive a visit by a practitioner at least once every two days.

N.J. Admin. Code § 8:43G-16.6

Amended by R.1992 d.72, effective 2/18/1992.
See: 23 N.J.R. 2590(a), 24 N.J.R. 590(a).
Diagnosis to be provided seven days prior to or 24 hours after admission.
Amended by R.2005 d.279, effective 9/6/2005.
See: 37 N.J.R. 709(a), 37 N.J.R. 3365(a).
Rewrote (b).
Amended by R.2011 d.055, effective 2/22/2011.
See: 42 N.J.R. 1774(a), 42 N.J.R. 2561(a), 43 N.J.R. 401(b).
Rewrote (b).