N.J. Admin. Code § 13:35-2B.11 - Recordkeeping

(a) Licensees shall make contemporaneous, permanent entries into professional treatment records that shall accurately reflect the treatment or services rendered. To the extent applicable, professional treatment records shall reflect:

1. The dates and times of all treatments;

2. The patient complaint;

3. The history;

4. Findings on appropriate examination;

5. Any orders for tests or consultations and the results thereof;

6. Diagnosis or medical impression; and

7. Treatment ordered. If medications are ordered, the patient record shall include:

i. Specific dosages, quantities and strengths of medications;

ii. The physician assistant's full name, printed or stamped, and the license number; and

iii. The supervising physician's full name, printed or stamped.

(b) If the information required pursuant to (a)8iii and iv appears at least once in the patient record, it need not be repeated each time a medication order is entered in the patient record.

(c) The physician assistant shall sign each entry in the patient record and record the designation "PA-C," "PA," or use the term "physician assistant" following his or her signature.

(d) To the extent a physician assistant is charged with independent responsibility for the provision of information used to prepare bills and claims forms, such information shall accurately reflect the treatment or services rendered.

Notes

N.J. Admin. Code § 13:35-2B.11

Amended by 50 N.J.R. 1368(a), effective 6/4/2018