New Jersey Administrative Code › Title 8 - HEALTH › Chapter 111 - FOOD AND DRUGS › Subchapter 19 - CLIENT CARE POLICIES AND SERVICES › Section 8:111-19.3 - Contents of clinical records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility
				shall require, at a minimum, the following 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, fee schedule and payment policy;
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 residential or outpatient substance abuse services;
6. A client treatment plan signed and dated by
				medical and clinical personnel as required by this chapter;
7. Clinical notes shall be entered on the day the
				service is rendered;
8. A log recording
				the clothing, personal effects, valuables, funds and other property deposited by the
				client with the facility for safekeeping, signed by the clients, his or her family
				or legally authorized representative and substantiated by receipts given to the
				client, his or her family or legally authorized representative;
9. 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;
10.
				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 or clinically contraindicated;
11. 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;
12. A record of self-administered medications, in
				accordance with the facility's policies and procedures and this chapter;
13. Documentation of the client's allergies in the
				clinical record on the outside front cover of the client record;
14. The results of laboratory, radiological,
				diagnostic, and/or screening tests performed;
15. Reports of accidents or incidents required to
				be reported to the administrator, governing authority, and/or the
				Department;
16. A record of referrals to
				other health care and social service providers, including those made to mental
				health providers;
17. Summaries of
				consultations;
18. Any signed, written
				informed consent forms or an explanation of why an informed consent was not obtained
				from the client;
19. A record of any
				treatment, drug or service offered by appropriate staff and refused by the
				client;
20. Record of psychotropic
				medications or mood altering medications prescribed to the client;
21. Instructions given to the client and/or the
				client's family for care following discharge;
22. The continuum of care plan; and
23. The continuum of care summary, in accordance
				with 26:8-5.