New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 53A - HOSPICE SERVICES MANUAL
Subchapter 2 - PROVIDER REQUIREMENTS
Section 10:53A-2.6 - Recordkeeping

Universal Citation: NJ Admin Code 10:53A-2.6

Current through Register Vol. 56, No. 18, September 16, 2024

(a) The medical record of the hospice beneficiary maintained by the hospice shall be complete and accurate and reflect the services provided. The medical record shall include, at a minimum, the following information:

1. Identification information;

2. Certification/recertification documents;

3. Informed consent documents;

4. Election forms;

5. Hospice eligibility forms;

6. Pertinent medical history and physical examination data;

7. Test results;

8. Initial and subsequent assessments;

9. Plan of care and updates; and

10. Complete documentation of all services and events (including evaluations, treatments, progress notes, etc.).

(b) All medical records shall be signed and dated by the professional staff person providing the service.

(c) The medical record shall be maintained and made available, as necessary, to the Division of Medical Assistance and Health Services or its agent for audit and review purposes in accordance with State law (see 30:4D-12 and (10:49-13.1) .

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