N.J. Admin. Code § 8:42C-7.4

Current through Register Vol. 56, No. 9, May 6, 2024

Section 8:42C-7.4 - Nursing entries in the medical/health record

(a) In accordance with written job descriptions and with this chapter, nursing personnel shall document in the patient's medical/health record:

1. The nursing plan of care in accordance with the facility's policies and procedures;

2. Clinical notes and progress notes;

3. A record of medications administered which shall include the following, documented by the nurse who administered the drug:

i. The name and strength of the drug;

ii. The date and time of administration;

iii. The dosage administered;

iv. The method of administration; and

v. The signature of the licensed nurse who administered the drug.

N.J. Admin. Code § 8:42C-7.4