New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 57 - PODIATRY SERVICES
Subchapter 1 - GENERAL PROVISIONS
Section 10:57-1.8 - Record keeping
Universal Citation: NJ Admin Code 10:57-1.8
Current through Register Vol. 56, No. 18, September 16, 2024
(a) Podiatrists shall keep such individual records as are necessary to fully disclose the kind and extent of the services provided and shall make such information available as the Division or its agents may request. For the initial examination, the following documentation shall be on the record, regardless of the setting where the examination was performed:
1. Date of service;
2. Chief complaint(s);
3. Pertinent historical and physical data;
4. Reports of diagnostic procedures ordered or performed;
5. Diagnosis;
6. Prescription (including medication) and treatment.
(b) Progress notes may be brief but shall include date(s) of service, changes in patient condition, specific medications and/or other treatments.
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