New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 58 - NURSE MIDWIFERY SERVICES
Subchapter 1 - GENERAL PROVISIONS
Section 10:58-1.11 - Recordkeeping; routine or follow-up visits

Universal Citation: NJ Admin Code 10:58-1.11

Current through Register Vol. 56, No. 18, September 16, 2024

(a) In order to document the record for reimbursement purposes, the progress note for routine office visits or follow-up care visits shall include the following:

1. In an office:
i. The purpose of the visit;

ii. Pertinent history obtained;

iii. Pertinent physical findings, including pertinent negative physical findings based on (a)i and ii above;

iv. The procedures, if any, with results;

v. Laboratory, X-ray, EKG, etc., ordered with results; and

vi. The diagnosis(es).

2. In a hospital or nursing facility setting:
i. An update of symptoms;

ii. An update of physical symptoms;

iii. A resume of findings of procedures, if any done;

iv. Pertinent positive and negative findings of lab, X-ray;

v. Additional planned studies, if any, and why; and

vi. Treatment changes, if any.

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