N.J. Admin. Code § 10:47-3.15 - Individual records

Current through Register Vol. 54, No. 7, April 4, 2022

(a) Individual records shall include the following data:
1. The date of admission;
2. The individual's social history and Medicaid numbers;
3. The individual's religious preference;
4. The name, address and telephone number of all personal physicians and dentists;
5. A physical examination by the physician within one week of admission which includes:
i. An examination for physical injury and disease;
ii. An assessment of the individual's general health; and
iii. Referrals to an appropriate medical specialist for further assessment and/or treatment;
6. Dental information, vision testing, and audiological evaluation, if not present in pre-admission data;
7. A prescribed medical program if required;
8. Physician's orders prescribing medication treatment and/or therapy;
9. Reports of clinical laboratory, X-ray, operation, and other diagnostic services;
10. Height and weight records;
11. A medically-prescribed diet, if required;
12. A medication administration record, including name and strength of drug, date and time of administration, dosage administered, route of administration and signature of the person administering the drug. (Initials may be used after the individual's full name, signature appears at least once on each page of the document);
13. Physician's periodic progress notes as required on the physical, emotional and behavioral status of the individual and course and results of treatment;
14. Progress notes of ancillary services including podiatry, physical therapy, optometry, speech and hearing, etc.;
15. The current Individual Habilitation Plan;
16. Previous reports of individual's social and behavioral progress to correspond to the current Individual Habilitation Plan; and
17. A record of the individual's personal property and funds.

Notes

N.J. Admin. Code § 10:47-3.15
Recodified from N.J.A.C. 10:47-3.16 by R.2007 d.72, effective 3/5/2007.
See: 38 N.J.R. 4352(a), 39 N.J.R. 777(a).
Former N.J.A.C. 10:47-3.15, Pre-admission, recodified to N.J.A.C. 10:47-3.14.

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