N.J. Admin. Code § 10:60-3.6

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

Section 10:60-3.6 - Clinical records

(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. Nursing assessments completed by the nursing agency. The most recent nursing assessment shall be retained in the beneficiary's active chart; the previous three years of assessments shall be retained onsite.

ii. A beneficiary-specific plan of care;

iii. Signed and dated progress notes describing the beneficiary's condition;

iv. Documentation of the supervision provided to the personal care assistant every 60 days;

v. A personal care assistant assignment sheet signed and dated weekly by the personal care assistant;

vi. Documentation that the beneficiary has been informed of rights to make decisions concerning his or her medical care;

vii. Documentation of the formulation of an advance directive; and

viii. 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.

N.J. Admin. Code § 10:60-3.6

Amended by 50 N.J.R. 1992(b), effective 9/17/2018

Amended by 54 N.J.R. 1721(a), effective 9/6/2022