New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 54 - PHYSICIAN SERVICES
Subchapter 2 - PHYSICIAN SERVICES-GENERAL
Section 10:54-2.10 - Minimum documentation; hospital or nursing facility
Universal Citation: NJ Admin Code 10:54-2.10
Current through Register Vol. 56, No. 18, September 16, 2024
(a) In a hospital or nursing facility, documentation shall include:
1. An update of symptoms;
2. An update of physical findings;
3. A resume of findings of procedures, if any are applicable;
4. The pertinent positive and negative findings of laboratory, X-Ray, electrocardiograms (ECGs), or other tests or consultations;
5. Any additional planned studies, if any, including the reasons for any studies; and
6. Treatment changes, if any.
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