N.J. Admin. Code § 10:161B-7.4 - Physician responsibilities
(a) Physicians who
provide medical care to clients in an outpatient substance use disorder
treatment program shall be responsible for:
1. Ensuring the provision or documentation of
a complete medical examination as required by
N.J.A.C.
10:161B-9.1;
2. Ordering, interpreting and documenting
medical screening tests, as appropriate;
3. Documenting all orders for medical
services to be provided to the client , including frequency and type of
treatment, therapies to be administered or coordinated, medications prescribed,
and date of discharge for medical services;
4. Ensuring that all medical interventions
are documented in the client 's clinical record and also shared with the nursing
staff; and
5. Ensuring that medical
follow-up of all acute or chronic illnesses and conditions are entered in the
client 's treatment plan, and that referrals for medical services are completed
during the client 's treatment, or as part of the client 's discharge/continuum
of care plan , as appropriate.
(b) In programs that provide medical services
on-site, the physician shall ensure that medical staff participate as part of
the multidisciplinary treatment team, and shall document medical services
provided in client progress notes.
Notes
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