N.J. Admin. Code § 10:54-2.11

Current through Register Vol. 56, No. 19, October 7, 2024

Section 10:54-2.11 - Minimum documentation; hospital discharge medical summary

(a) When an inpatient is discharged from the hospital to the care of another medical facility (such as a nursing facility or a community home care agency), a legible discharge and medical summary shall be prepared and signed by the attending physician.

(b) The summary should cover the pertinent findings of the history, physical examination, diagnostic and therapeutic modalities, consultations, plan of care or therapy, medications, recommendations for follow-up care and final diagnosis related to the patient's hospitalization. Recommendations should also be made for further medical care and should be forwarded to the institution or agency to which the patient has been referred.