New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 66 - INDEPENDENT CLINIC SERVICES
Subchapter 3 - HEALTHSTART
Section 10:66-3.11 - Records: documentation, confidentiality and informed consent for HealthStart comprehensive maternity care providers
Current through Register Vol. 56, No. 18, September 16, 2024
(a) HealthStart maternity care providers shall have policies which protect patient confidentiality, provide for informed consent, and document prenatal, labor, delivery and postpartum services in accordance with N.J.A.C. 10:54-6.
(b) An individual record shall be maintained for each patient throughout the pregnancy.
(c) Each record shall be confidential and shall include at least the following: history and physical examination findings, assessment, a care plan, treatment services, laboratory reports, counseling and health instructions provided, and documentation of referral and follow-up services.
(d) There shall be policies and procedures for appropriate informed consent for all HealthStart services.