New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 54 - PHYSICIAN SERVICES
Subchapter 2 - PHYSICIAN SERVICES-GENERAL
Section 10:54-2.8 - Minimum documentation; established patient
Universal Citation: NJ Admin Code 10:54-2.8
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The following minimum documentation shall be entered in the progress notes of the medical record for the service designated by the procedure codes for ESTABLISHED PATIENT:
1. In an office or Residential Health Care Facility:
i. The purpose of the visit;
ii. The pertinent physical, family and social history obtained;
iii. A record of pertinent physical findings, including pertinent negative findings based upon i and ii above;
iv. Procedures performed, if any, with results;
v. Laboratory, X-Ray, electrocardiogram (ECG), or any other diagnostic tests ordered, with the results of the tests; and
vi. Prognosis and diagnosis.
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