N.J. Admin. Code § 10:161B-7.3 - Medical policies and medical staff bylaws

(a) The medical director, in conjunction with the medical staff, shall develop, implement and review annually, medical policies, including medical staff bylaws that shall be subject to the review and approval of the governing authority and the administrator, and are consistent with New Jersey laws and rules.
(b) The written medical policies and bylaws shall include, but need not be limited to, the following:
1. A plan for convening medical staff meetings that are documented by minutes;
2. A procedure for reviewing credentials and delineating qualifications of medical staff, appointments and reappointments, evaluation of medical care, and the granting, denial, curtailment, suspension, or revocation of medical staff privileges;
3. Specifications for verbal orders, including who may give verbal orders and who may receive them;
4. A system for completion of entries in the client clinical records by members of the medical staff, including identification of a time limit for completion of the clinical record, which must not exceed 30 days following a client's last treatment or discharge;
5. For those programs serving pregnant women, and women and children, a plan for ensuring that the medical needs of the fetus, children and mothers are adequately assessed and met during treatment;
6. Identification of the program's quality assurance plan for medical services and how that plan will coordinate with the nursing quality assurance plan; and
7. Medical staffing patterns.


N.J. Admin. Code § 10:161B-7.3

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