N.J. Admin. Code § 10:60-3.6 - Clinical records

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

(a) Recordkeeping for personal care assistant services shall include the following:
1. Clinical records and reports shall be maintained for each beneficiary, covering the medical, nursing, social and health related care in accordance with accepted professional standards. Such information shall be readily available, as required, to representatives of the Division or its agents.
2. Clinical records shall contain, at a minimum:
i. An initial nursing assessment;
ii. A six-month nursing reassessment;
iii. A beneficiary-specific plan of care;
iv. Signed and dated progress notes describing the beneficiary's condition;
v. Documentation of the supervision provided to the personal care assistant every 60 days;
vi. A personal care assistant assignment sheet signed and dated weekly by the personal care assistant;
vii. Documentation that the beneficiary has been informed of rights to make decisions concerning his or her medical care;
viii. Documentation of the formulation of an advance directive; and
ix. Documentation of approved nurse delegated tasks and documentation of training on performance of those tasks.
3. All clinical records shall be signed and dated by the registered professional nurse, in accordance with accepted professional standards, and shall include documentation described in (a)2 above.

Notes

N.J. Admin. Code § 10:60-3.6
Amended by 50 N.J.R. 1992(b), effective 9/17/2018

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