N.J. Admin. Code § 10:54-2.7

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

Section 10:54-2.7 - Minimum documentation; initial visit; new patient

(a) The following minimum documentation shall be entered on the medical record, regardless of the setting where the examination is performed, for the service claimed by use of the procedure codes for Initial visit--New patient:

1. Chief complaint(s);

2. Complete history of the present illness and related systemic review, including recordings of pertinent negative findings;

3. Pertinent past medical history;

4. Pertinent family and social history;

5. A record of a full physical examination pertaining to, but not limited to, the history of the present illness and including recordings of pertinent negative findings;

6. Diagnosis(es) and the treatment plan, including ancillary services and medications ordered;

7. Laboratory, X-Rays, electrocardiograms (ECGs), and any other diagnostic tests ordered, with the results; and

8. The specific services rendered and/or modality used (for example, biopsies, injections, individual and/or group psychotherapy, and family therapy).

N.J. Admin. Code § 10:54-2.7