New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 66 - INDEPENDENT CLINIC SERVICES
Subchapter 5 - AMBULATORY SURGICAL CENTER (ASC)
Section 10:66-5.4 - Medical records

Universal Citation: NJ Admin Code 10:66-5.4

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

(a) In addition to the requirements set forth at 42 CFR 416.47, medical records in an ASC shall include, but not be limited to:

1. Patient identification;

2. Significant medical history and results of physical examination;

3. Pre-operative diagnostic studies (entered before surgery), if performed;

4. Findings and techniques of the operation, including a pathologist's report on all tissues removed during surgery, except those exempted by the governing body;

5. Any allergies and abnormal drug reactions;

6. Entries related to anesthesia administration;

7. Documentation of properly executed informed consent; and

8. Discharge diagnosis.

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