N.J. Admin. Code § 10:47-6.7

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:47-6.7 - Medical records

(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.

N.J. Admin. Code § 10:47-6.7