N.J. Admin. Code § 10:54-2.8

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

Section 10:54-2.8 - Minimum documentation; established patient

(a) The following minimum documentation shall be entered in the progress notes of the medical record for the service designated by the procedure codes for ESTABLISHED PATIENT:

1. In an office or Residential Health Care Facility:

i. The purpose of the visit;

ii. The pertinent physical, family and social history obtained;

iii. A record of pertinent physical findings, including pertinent negative findings based upon i and ii above;

iv. Procedures performed, if any, with results;

v. Laboratory, X-Ray, electrocardiogram (ECG), or any other diagnostic tests ordered, with the results of the tests; and

vi. Prognosis and diagnosis.

N.J. Admin. Code § 10:54-2.8