New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 161B - STANDARDS FOR LICENSURE OF OUTPATIENT SUBSTANCE USE DISORDER TREATMENT FACILITIES › Subchapter 18 - CLINICAL RECORDS › Section 10:161B-18.3 - Contents of clinical records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility
				shall require the following, at a minimum, to be included in the clinical
				record:
1. Client identification data,
				including name, date of admission, address, date of birth, race, religion
				(optional), gender, and the name, address, and telephone number of the
				person(s) to be notified in an emergency;
2. Admission, discharge and other reports
				required by this chapter as part of the substance abuse client management
				information system, as well as previous treatment records and
				correspondence;
3. The client's
				signed acknowledgment that he or she has been informed of and received a copy
				of client rights;
4. A summary of
				the admission interview, and a copy of the biopsychosocial
				assessment;
5. Documentation of the
				medical history and physical examination signed and dated by the physician for
				opioid treatment and detoxification clients, or the comprehensive health
				history for clients receiving other outpatient services;
6. A client treatment plan signed and dated
				by medical and clinical personnel as required by this chapter;
7. In programs providing IOP and PC services,
				clinical notes, including progress notes for individual, group, and family
				counseling sessions as well as psycho-educational groups, shall be documented
				in each client's record no less than weekly by a summary note for each
				individual and group session listing the date and topic of all treatment
				sessions attended, and a narrative of his or her participation and treatment
				progress. Weekly summary notes shall be based on the compilation of the session
				notes of all clinicians providing services to the client;
8. In programs providing OP services,
				clinical notes, including progress notes for individual, group, and family
				counseling sessions as well as psycho-educational groups, shall be documented
				in each client's record by contact listing the date and topic of all treatment
				sessions attended, and a narrative of his or her participation and treatment
				progress;
9. In programs providing
				OTP services, clinical notes, including progress notes for individual, group,
				and family counseling sessions as well as psycho-educational groups, shall be
				documented in each client's record by contact listing the date and topic of all
				treatment sessions attended, and a narrative of his or her participation and
				treatment progress. Medication dispensing requires documentation per contact
				but does not require a narrative or summary;
10. Medical notes for services provided by
				physicians, nurses and other licensed medical practitioners shall be entered in
				the client record on the day of service;
11. Documentation of the client's
				participation in the development of his or her treatment plan, or documentation
				by a physician or licensed clinician that the client's participation is
				medically contraindicated;
12. A
				record of medications administered, including the name and strength of the
				drug, date and time of administration, the dosage administered, method of
				administration, a description of reactions if observed, and signature of the
				person who administered the drug;
13. A record of self-administered
				medications, in accordance with the program's policies and
				procedures;
14. A record of
				medications dispensed or prescribed for home use;
15. Documentation of the client's allergies
				in the clinical record and on the outside front cover of the client
				record;
16. The results of
				laboratory, radiological, diagnostic, and/or screening tests
				performed;
17. Reports of
				accidents;
18. A record of
				referrals to other health care and social service providers;
19. Summaries of consultations;
20. Any signed, written informed consent
				forms or an explanation of why an informed consent was not obtained;
21. A record of any treatment, drug, or
				service offered by appropriate program staff and refused by the
				client;
22. Instructions given to
				the client and/or the client's family for care following discharge;
23. The discharge/continuum of care plan;
				and
24. The discharge/continuum of
				care summary, in accordance with
				26:8-5.