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.
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.