New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 37A - LICENSED COMMUNITY RESIDENCES FOR ADULTS WITH MENTAL ILLNESSES
Subchapter 5 - CLINICAL RECORD DOCUMENTATION
Section 10:37A-5.1 - General requirements
Universal Citation: NJ Admin Code 10:37A-5.1
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The PA shall maintain written records for each consumer residing in supervised housing.
(b) The PA shall maintain the confidentiality of all records (in accordance with all applicable Federal and State laws) and shall securely store such records in a manner as to provide access only to authorized persons.
(c) Each consumer record shall be maintained in an organized, up-to-date fashion and shall include documentation of all services provided and contacts with consumers, including, as appropriate, the following documents:
1. A consumer service
agreement that meets the requirements of 10:37A-4.2
;
2. A comprehensive rehabilitation needs
assessment that meets the requirements of 10:37A-4.3
;
3. A nursing assessment that meets the
requirements of 10:37A-4.4
;
4. An individualized
rehabilitation plan that meets the requirements of 10:37A-4.5
;
5. Progress notes that meet the requirements
of 10:37A-5.2
;
6. A termination summary that meets the
requirements of 10:37A-5.3
;
and
7. If the PA charges consumers
fees, appropriate financial records that meet the requirements of
10:37A-5.4(a)
.
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