New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 68 - CHIROPRACTIC SERVICES
Subchapter 1 - GENERAL PROVISIONS
Section 10:68-1.7 - Recordkeeping

Universal Citation: NJ Admin Code 10:68-1.7

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

(a) All chiropractors shall keep such individual records as are necessary to fully disclose the kind and extent of services provided in accordance with the rules of the Board of Chiropractic Examiners at N.J.A.C. 13:44E-2.2 and the Division, at N.J.A.C. 10:49-9.7 and 9.8.

1. This information shall be made available upon request of the New Jersey Medicaid/NJ FamilyCare program or its agents.

(b) Patient visits are subject to post-payment review of the medical necessity for treatment. The absence of medical necessity subjects the provider to recovery of fees already received.

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

1. The date of service;

2. The chief complaint(s);

3. Pertinent historical and physical data;

4. Reports of diagnostic procedures ordered;

5. The diagnosis(es); and

6. The treatment plan.

(d) Subsequent progress notes may be brief, but shall include date, pertinent history, physical findings and specific treatment.

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