Question

For the state of New Jersey:

Identify the location of the state specific guidelines for medical record requirements for a physician office or a hospital by using the state statutes and not Findlaw.

Identify the source of the information.

Summarize the documentation requirements.

Summarize how you identified the location of the information.

Answer 1

New jersey state department of health and senior services location and method of retrieval of medical records:
Policies and procedures:
-Active medical records should be kept at the nurses station of the resident's unit.
-Use commonly used standard professional abbreviations in the facility medical record.
-Medical records should be organized with a uniform format across all records..
-It can be initiated for each residents upon admission.It include all additional information given below:
1, patient data
2,physician data or nurses data..
3,complete information about diagnosis,lab,meical and surgical procedure..
4, History and medical result of physical examination
5,assessment plan including signs ans symptoms,treatment,psychological condition should be enter into the record..
6,physician order in last 3 months
7Telephone orders from physician
8, records of medication provided
9, consultation reports for the last six months
10,informed consent form
11, discharge plan in the community,ICU settings,nursing home
12,medical record should be completed within 30days of discharge
13, medical record should be signed with computerized
14, electronic signature should be used to avoid unauthorized use of computer-generated signature
15,FAX is used,entries to the medical record according to physician,nurse sign in original order,history and examination at an off-site location.
16, medical record should be submitted within 72hours..FAX copy should be original.
17, legally authorized representative can get the photocopy of medical record,furnished at the fee based on actual costs..
18, Access to the medical record only with limitation to ptotect the residents..
19, verbal explanation can be acceptable
20,provide brief comment from resident at the end of the medical record..
Advisory medical records:
-Name must be entered on the cover of the forst page..
-comprehensive discharge summary with all statisitical and narrative information..
-Medical records for a period of not less than 10years following the most recent discharge patient reaches age 23,but it is the longer period..in addition,discharge summary sheet shall be retained for a period of 20years following the most recent discharge of the patient..X-ray films shall be retained for a period of five years..
Advisory staff qualification:
Medical record practitioner who is certified registered record admnistrator by the American medical record association..