New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 58 - NURSE MIDWIFERY SERVICES
Subchapter 1 - GENERAL PROVISIONS
Section 10:58-1.14 - Recordkeeping; home visit or house call

Universal Citation: NJ Admin Code 10:58-1.14

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

(a) The record and documentation of a home visit or house call shall become part of the office progress notes and shall include, as appropriate, the following information:

1. The purpose of the visit;

2. The pertinent history obtained;

3. Pertinent physical findings, including pertinent negative physical findings based on (a)1 and 2 above;

4. The procedures, if any performed, with results;

5. Laboratory, X-ray, ECG, etc., ordered with results; and

6. The diagnosis(es) plus treatment plan status relative to present or pre-existing illness(es) plus pertinent recommendations and actions.

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