N.J. Admin. Code § 10:47-6.7 - Medical records

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

(a) An accurate, complete and up to date medical record shall be maintained for each individual. This record shall include:
1. A list of all current diagnoses, which shall be located in an identified area of the record;
2. A list of all significant past illnesses, surgeries and trauma, which shall be located in an identified area of the record;
3. A health status review by licensed professional nurses as needed but at least annually;
4. An annual physical examination;
5. An immunization record;
6. List of known allergies;
7. Vision examination every three years;
8. Report of annual dental examination or accurate dental records;
9. Physician's orders;
10. Physician's periodic progress notes on the physical, emotional, and behavioral status of the individual;
11. Nurse's and clinical notes;
12. Reports of clinical laboratory x-rays, surgical, or other diagnostic services;
13. Height and weight records; and
14. A medication administration record.

Notes

N.J. Admin. Code § 10:47-6.7

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