New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 67 - PSYCHOLOGICAL SERVICES
Subchapter 1 - INTRODUCTION
Section 10:67-1.4 - Recordkeeping

Universal Citation: NJ Admin Code 10:67-1.4

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

(a) Psychologists shall keep such individual records as may be necessary to disclose fully the kind and extent of services provided and shall make such information available when requested by the New Jersey Medicaid/NJ FamilyCare program or its agents. The recordkeeping shall document the services provided as they relate to the procedure code(s) used for reimbursement purposes (see N.J.A.C. 10:67-3, Healthcare Common Procedure Coding System).

(b) For the initial examination, the record shall include, as a minimum, the following:

1. Date(s) of service rendered;

2. Signature of the psychologist;

3. Chief complaint(s);

4. Pertinent historical, social, emotional, and additional data;

5. Reports of evaluation procedures undertaken or ordered;

6. Diagnosis; and

7. The intended course of treatment and tentative prognosis.

(c) For subsequent progress notes made for each Medicaid/ NJ FamilyCare patient contact, the following shall be included on the psychotherapeutic progress note:

1. Date(s) and duration of service (for example, hour, half-hour);

2. Signature of the psychologist;

3. Name(s) of modality used, such as individual, group, or family therapy;

4. Notations of progress, impediments, or treatment complications; and

5. Other components, such as dates or information not included in (c)1 through 4 above, which may be important to the clinical description and prognosis.

6. One or more of the following components shall be recorded to delineate the visit and establish its uniqueness. (Not all of the components need be included):
i. Symptoms and complaints;

ii. Affect;

iii. Behavior;

iv. Focus topics; and

v. Significant incidents or historical events.

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