N.J. Admin. Code § 8:43J-14.3

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

Section 8:43J-14.3 - Contents of medical records

(a) The child's complete medical record shall include, but not be limited to, the following:

1. Child identification data, including:

i. Name;

ii. Date of admission;

iii. Address;

iv. Date of birth;

v. Race;

vi. Religion (if parent elects to provide);

vii. Sex;

viii. Referral source;

ix. Payment plan;

x. Travel directions to the child's home;

xi. Name, address and contact telephone number of the child's parent; and

xii. Name, address and contact telephone number of the person(s) to be notified in an emergency;

2. The parent's signed acknowledgment that the facility has informed them of, and given them a copy of, the child's rights pursuant to N.J.A.C. 8:43J-4;

3. The preadmission assessment of the child's home environment pursuant to N.J.A.C. 8:43J-5.1;

4. A summary of the admission interview pursuant to N.J.A.C. 8:43J-5.2;

5. Documentation of the child's immunization record, medical history and physical examination, signed and dated by the child's primary health care provider;

6. The information required pursuant to N.J.A.C. 8:43J-8.4(b);

7. Advance directives and related documentation, as applicable, pursuant to N.J.A.C. 8:43J-3.5(c);

8. Assessments developed by each service providing care to the child;

9. Initial and interdisciplinary plans of care;

10. Clinical notes, which shall be entered on the day service is rendered;

11. Concise, accurate and initialed case notes reflecting progress toward goal achievement or reasons for lack of progress;

12. A record of medications administered, including the name and strength of the medication, date and time of administration, dosage administered, method of administration and legible signature of the person who administered the medication;

13. Documentation of allergies and any special precautions to be taken in the medical record and on its outside front cover;

14. Any signed written informed consent forms;

15. All orders for treatment, medication, therapy and diets, signed by the prescriber.

i. Orders for speech-language pathology, physical therapy and occupational therapy services shall include specific modalities and the frequency of treatment;

16. An attendance record listing all of the days on which the child was in the facility;

17. A current photograph of the child;

18. Documentation of Department determination of Medicaid clinical eligibility for PMDC services pursuant to N.J.A.C. 10:166, as applicable; and

19. The discharge summary, in accordance with N.J.S.A. 26:8-5 et seq.

N.J. Admin. Code § 8:43J-14.3

Notice of readoption with technical change.
See: 48 N.J.R. 2354(a).