N.J. Admin. Code § 8:43A-21.4

Current through Register Vol. 56, No. 24, December 18, 2024

Section 8:43A-21.4 - Medical records

(a) The complete medical record for prenatal patients shall include, but not be limited to, documentation of assessment of uterine growth, fetal heart tones, estimated delivery date, urine tests for protein, blood pressure, weight gain, and an updated assessment of obstetrical risk, and shall be in conformance with N.J.A.C. 8:33C-4.3.

(b) The facility shall establish and implement written policies and procedures regarding the transfer of patient information when the patient is transferred to another health care facility, or if the patient has been an inpatient and becomes an outpatient at the same facility, to ensure continuity of care. In the case of a prenatal patient, a copy or summary of the patient's prenatal medical record shall be transferred, no later than 34 weeks gestation, from the facility to the inpatient facility where delivery is to take place. The facility shall also request a copy or summary of the patient's labor, delivery and postpartum record from the inpatient facility prior to any scheduled postpartum visits.