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N.J. Admin. Code § 10:60-2.4 - Clinical records
New JerseyregulationNJ DHS, Division of Medical Assistance and Health Services (DMAHS)· effective 2022-09-06
What this rule requires your agency to do
- 1Clinical notes by nurses, social workers, and special therapists must be written, signed, and dated on the day each service is provided.(N.J. Admin. Code § 10:60-2.4 - Clinical records)
- 2Summary reports of pertinent factors from clinical notes must be submitted to the attending physician/practitioner at least every 60 days.(N.J. Admin. Code § 10:60-2.4 - Clinical records)
- 3The home health agency must maintain clinical records containing pertinent past and current information, recorded according to accepted professional standards, for each beneficiary receiving home health care services.(N.J. Admin. Code § 10:60-2.4 - Clinical records)
- 4The clinical record must include, at a minimum: a plan of care, identifying information, the physician/practitioner's name/address/phone, clinical notes written/signed/dated on the day each service is provided, periodic response-to-service evaluation notes, summary reports submitted to the attending physician at least every 60 days, and transfer information when applicable.(N.J. Admin. Code § 10:60-2.4 - Clinical records)
Applies to: personal care
Requires home health agencies to maintain clinical records for each beneficiary recorded to accepted professional standards, and specifies the minimum required record contents.
Regulatory information, not legal advice — always confirm against the cited official source. Verification reduces error; it does not certify compliance.