N.J. Admin. Code § 8:43A-24.13

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

Section 8:43A-24.13 - Patient care plan

(a) The referring or transferring facility shall provide the receiving facility the most recent patient care plan, copies of summaries of the patient's treatments, records, medical progress, a description of dietary care, a summary of the patient's current needs and results of laboratory tests prior to transfer.

(b) Within one calendar month of initiation of dialysis treatment at the facility, a written plan of care shall be developed for each ambulatory dialysis patient by a multidisciplinary team consisting of at least, a nephrologist, a transplant surgeon or designee, a registered professional nurse, a dietitian, and a licensed social worker. The plan of care shall specify observable and measurable goals and expected patient outcomes. The multidisciplinary team shall analyze patient outcomes on a regular basis to assess the patient's progress and evaluate current and future treatment modalities and modify the plan as necessary.

(c) Every six months at minimum, the multidisciplinary team shall discuss and review the written patient care plan with each ambulatory dialysis patient and/or family, and shall revise as needed.

(d) Each member of the multidisciplinary team shall enter progress notes into the chronic dialysis patient's medical record. Progress notes by the physician, registered professional nurse and dietitian shall be entered in the patient's medical record at least monthly and by the social worker at least quarterly.

N.J. Admin. Code § 8:43A-24.13