New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 58 - NURSE MIDWIFERY SERVICES
Subchapter 1 - GENERAL PROVISIONS
Section 10:58-1.10 - Recordkeeping; initial visit
Universal Citation: NJ Admin Code 10:58-1.10
Current through Register Vol. 56, No. 18, September 16, 2024
(a) In order to receive reimbursement for an initial visit, the following documentation, at a minimum, shall be on the record, regardless of the setting where the examination was performed:
1. The chief complaint(s);
2. A complete history of the present illness and related systemic review-- including recordings of pertinent negative findings;
3. A pertinent past medical history;
4. A pertinent family history;
5. A full physical examination pertaining to, but not limited to, the history of the present illness and including recordings of pertinent negative findings; and
6. The working diagnoses and treatment plan including ancillary services and drugs ordered.
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