New Jersey Administrative Code › Title 8 - HEALTH › Chapter 39 - STANDARDS FOR LICENSURE OF LONG-TERM CARE FACILITIES › Subchapter 35 - MANDATORY MEDICAL RECORDS › Section 8:39-35.2 - Mandatory policies and procedures for medical records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each active medical
				record shall be kept at the nurses' station for the resident's unit.
(b) The facility shall maintain for staff use a
				current list of standard professional abbreviations commonly used in the facility's
				medical records.
(c) Medical records
				shall be organized with a uniform format across all records.
(d) A medical record shall be initiated for each
				resident upon admission. The current medical record shall be readily available and
				shall include at least the following information, when such information becomes
				available:
1. Legible identifying data, such as
				resident's name, date of birth, sex, address, and next of kin, and person to notify
				in an emergency;
2. The name, address,
				and telephone number of the resident's physician, an alternate physician, or
				advanced practice nurse and dentist;
3.
				Complete transfer information from the sending facility, including results of
				diagnostic, laboratory, and other medical and surgical procedures, and a copy of the
				resident's advance directive, if available, or notice that the resident has informed
				the sending facility of the existence of an advance directive;
4. A history and results of a physical
				examination, including weight, performed by the physician or advanced practice nurse
				on admission, in accordance with
				8:39-11.2(c)  and
				results of the most recent examination by the physician, or advanced practice nurse,
				or New Jersey licensed physician assistant;
5. An assessment and plan of care made by each
				discipline involved in the resident's care;
6. Clinical notes for the past three months
				incorporating written, signed and dated notations by each member of the health care
				team who provided services to the resident, including a description of signs and
				symptoms, treatments and/or drugs given, the resident's reaction, and any changes in
				physical or emotional condition entered into the record when the service was
				provided;
7. All physician's or advanced
				practice nurse's orders for the last three months;
8. Telephone orders, each of which shall be
				countersigned by a physician or advanced practice nurse within seven days, except
				for orders for non-prescription drugs or treatments, which shall be signed at the
				physician's or advanced practice nurse's next visit to the resident;
9. Records of all medications and other treatments
				that have been provided during the last three months;
10. Consultation reports for the last six
				months;
11. Records of all laboratory,
				radiologic, and other diagnostic tests for the last six months;
12. Records of all admissions, discharges, and
				transfers to and from the facility that occurred in the last three months;
13. Signed consent and release forms;
14. Documentation of the existence, or
				nonexistence, of an advance directive and the facility's inquiry of the resident
				concerning this;
15. A discharge plan
				for those residents identified by the facility as likely candidates for discharge
				into the community or a less intensive care setting; and
16. A discharge note written on the day of
				discharge for residents discharged to the community, a less intensive care setting,
				another nursing home or hospital, which includes at least the diagnosis, prognosis,
				and psychosocial and physical condition of the resident.