N.J. Admin. Code § 13:44L-5.9

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

Section 13:44L-5.9 - Documentation of patient services

(a) Licensed polysomnographic technologists shall make contemporaneous, permanent entries into facility patient records, which shall accurately reflect the polysomnographic services rendered. These entries shall contain, at a minimum:

1. An intake record;

2. The date of service;

3. Reasons for the visit;

4. The name and license number of the licensed polysomnographic technologist, technician or trainee who provided services;

5. Polysomnographic observation notes on each service provided by the licensed polysomnographic technologist, technician or trainee. Observation notes entered by a polysomnographic technician or trainee shall include the signature of the technician's or trainee's supervising polysomnographic technologist or licensed physician; and

6. A summary of any verbal orders taken by the licensed polysomnographic technologist or technician.

N.J. Admin. Code § 13:44L-5.9