N.J. Admin. Code § 10:161B-18.4 - Requirements for clinical record entries

(a) The facility shall require that all orders for client care be prescribed in writing, signed and dated by the prescriber(s), in accordance with State law.
1. All medical orders, including verbal orders, shall be verified or countersigned in writing within 72 hours and in accordance with State law.
(b) The facility shall require that all entries in the clinical record be typewritten or written legibly in black or blue ink, dated and signed by the person entering them, or authenticated if a computerized clinical records system is used.
1. If computer-generated orders with a physician's electronic signature are used, the program shall develop a procedure to ensure the confidentiality of each electronic signature and to prohibit the improper or unauthorized use of any computer-generated signature.
2. If a facsimile communications system (FAX) is used, entries into the clinical record shall be in accordance with the following procedures:
i. The physician shall sign the original order, and include the history and/or examination if conducted at an off-site location;
ii. The original order shall be transmitted by FAX system to the program for inclusion in the clinical record;
iii. The physician shall submit the original for inclusion in the clinical record within seven days, unless a plain paper laser facsimile process was used; and
iv. The copy transmitted by FAX system shall be replaced by the original, unless a plain paper laser facsimile process was used.
(c) The clinical record shall be completed within the time frame specified in the clinical records policies and procedures, which shall be no longer than 30 days from the last treatment or discharge.
(d) The clinical record shall be available to the client's substance abuse practitioner or clinician involved in the client's care at all times during the hours of operation.

Notes

N.J. Admin. Code § 10:161B-18.4

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