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-5.2 - Progress notes
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The PA shall document and maintain progress notes for each consumer on a weekly basis or more frequently in times of crisis or transition.
(b) Progress notes shall indicate the level of goal attainment, services provided, significant events, and contacts with other service providers. PA staff shall use the information contained in progress notes to set levels of care and to develop and revise the individualized rehabilitation plan and ongoing assessments related to a consumer's WRAP (R), where one exists.
(c) PA staff shall sign, date, and indicate the time of entry for every progress note they write and shall include their staff titles.
(d) Progress notes shall document ongoing communication with other service providers.
