N.J. Admin. Code § 8:43A-8.5

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

Section 8:43A-8.5 - Nursing portion of the medical record

(a) In accordance with written job descriptions and with these rules, nursing personnel shall enter the following in the patient's medical record:

1. The nursing portion of the patient plan of care, in accordance with the facility's policies and procedures;

2. Clinical notes; and

3. A record of medications administered. After each drug administration, the following shall be documented by the nurse who administered the drug: name and strength of the drug, date and time of administration, dosage administered, method of administration, and signature of the nurse who administered the drug.

N.J. Admin. Code § 8:43A-8.5