New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 37 - COMMUNITY MENTAL HEALTH SERVICES ACT
Subchapter 6 - GENERAL ADMINISTRATIVE REQUIREMENTS FOR ALL STATE-FUNDED COMMUNITY MENTAL HEALTH PROGRAM ELEMENTS
Section 10:37-6.75 - Inpatients records: supplementary content requirements

1. Results of evaluations and services: Psychological testing, educational and socio-vocational evaluations, pathology and clinical laboratory examinations, radiology examinations, psychiatric and other medical treatment, and any other diagnostic or therapeutic procedure performed.

2. Psychiatric evaluation: Mental status, psychodynamics, sociodynamics, precipitating stress, premorbid personality, tentative diagnosis, a treatment plan, prognosis based on that plan, and subsequent modifications of the plan.

3. Physical examination if performed, shall include pertinent findings.

4. Admission notes: All additions to the history and subsequent changes in the physical findings.

5. Progress notes: Written by medical staff members or other individuals who have been granted clinical privileges, nursing staff, the interdisciplinary treatment team members, consultants, community liaison staff, and/or ancillary service staff.

6. Progress notes: By staff cited in (a)5 above, documenting the treatment plan, a pertinent chronological report of the client's functional abilities and clinical condition, changes in each condition and the results of service/treatment. Progress notes should include only pertinent, meaningful observations and information.

7. Medical orders: Written only by members of the medical staff and medical residents.

8. Telephone orders: Given by a physician only; shall be accepted and written by a licensed nurse only; such action shall be limited to urgent circumstances. Telephone orders shall be authenticated by the responsible physician within 24 hours, specifying date of initial contact or admission to the program.

9. History: Incorporating the client's chief complaint, details of present illness, past service history, and social, vocational and family history. The history shall be a record of information provided by the client or by his agent.

10. A Summation, in the event of a patient's death, in the form of a discharge summary, shall include the circumstances leading to death and shall be signed by a physician.

11. An autopsy shall be performed whenever indicated and results recorded in the record within 72 hours; the complete protocol shall be made a part of the record within three months.