New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 54 - PHYSICIAN SERVICES
Subchapter 6 - HEALTHSTART-MATERNITY AND PEDIATRIC CARE SERVICES
Section 10:54-6.12 - Records: documentation, confidentiality and informed consent for HealthStart maternity care providers
Current through Register Vol. 56, No. 18, September 16, 2024
(a) HealthStart Maternity Medical Care providers must have policies and procedures which protect patient confidentiality, provide for informed consent and document prenatal, labor, delivery and postpartum services in accordance with the "New Jersey State Department of Health and Senior Services Guidelines for HealthStart Maternity Care Providers" (N.J.A.C. 10:66-3).
(b) An individual record must be maintained for each patient throughout the pregnancy.
(c) Each record must be confidential and must include at least the following: history and physical examination findings; assessment; a Plan of Care; treatment services; laboratory reports; counseling and health instructions; documentation of referral and follow-up services; and the Medicaid eligibility status, including presumptive eligibility determination and follow-up, as appropriate.
(d) There shall be policies and procedures for appropriate informed consent for all HealthStart services.
