New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 58 - NURSE MIDWIFERY SERVICES
Subchapter 1 - GENERAL PROVISIONS
Section 10:58-1.15 - Recordkeeping requirements for birth center services
Universal Citation: NJ Admin Code 10:58-1.15
Current through Register Vol. 56, No. 18, September 16, 2024
(a) Medical records maintained by a birth center for the maternity services shall include, but not be limited to:
1. Patient identification;
2. An initial medical history, results of physical examination, and diagnosis;
3. Progress notes for each visit, which shall include interim history, physical findings, and disposition;
4. Reports of laboratory and other diagnostic studies, and consultation;
5. Any allergies and abnormal drug reactions;
6. A report of the delivery process;
7. The status and condition of the newborn;
8. Documentation of properly executed informed consent of each woman enrolling in a birth center for treatment; and
9. A discharge diagnosis.
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