Resident records | NJ

RESIDENT RECORDS

 

8:36-15.1       Health record

 

A current, complete health record shall be maintained for each resident who is receiving health care services.

 

8:36-15.2       Record availability

 

The records required by this subchapter shall be maintained for all residents and shall be kept available on the premises for review at any time by representatives of the Department.

 

8:36-15.3       Confidentiality

 

  • Records and information regarding the individual resident shall be considered confidential and the resident shall have the opportunity to examine such records, in accordance with facility or program

 

  • The written consent of the resident shall be obtained for release of his or her records to any individual outside the facility or program, except in the case of the resident’s transfer to another health care facility, or as required by law, third-party payor, or authorized government

 

8:36-15.4       Record retention

 

All records shall be maintained for a period of 10 years after the discharge of a resident from the assisted living residence, comprehensive personal care home or assisted living program.

 

8:36-15.5       Register

 

(a) A register which contains a current census of all residents, along with other pertinent information, shall be maintained by each assisted living residence, comprehensive personal care home, or assisted living program. The following standards for maintaining the register shall apply:

 

  1. The administrator or the administrator’s designee shall make all entries in the register and shall be responsible for its maintenance and safe-keeping;

 

  1. The register shall be kept up-to-date at all times. Admissions, discharges and discharge destination, and other changes shall be recorded within 48 hours;

 

  1. The register, which is a permanent record, shall be kept in a safe place;

and

 

  1. All entries into the register shall be clear, legible, and written in ink or

typed.

 

8:36-15.6       Residents’ individual records

 

  • Each resident’s record shall include at least the following:

 

  1. The resident’s completed admission application and all records forwarded to the facility;

 

  1. The resident’s name, last address, date of birth, name and address of sponsor or interested agency, date of admission, date of discharge (and discharge destination) or death, the name, address and telephone number of physician to be called, and the name and address of nearest relative, guardian, responsible person, or interested agency, together with any other information the resident wishes to have recorded;

 

  1. A copy of the resident’s advanced directive, if applicable; and

 

  1. A copy of the resident’s general service plan and/or health service plan, if

 

  • All assessments and treatments by health care and service providers shall be entered according to the standards of professional practice. Documentation and/or notes from all health care and service providers shall be entered according to the standards of professional

 

8:36-15.7       Record of death

 

  • Whenever a resident dies in the assisted living residence, the administrator or the administrator’s designee shall:

 

  1. Promptly notify a family member, guardian or other designated person of the death of the resident. Notification shall be made at the time of the occurrence, and the time between the resident’s death and notification shall not exceed one hour; and

 

  1. Include in the resident’s record written documentation from the physician of the date and time of death, the name of the person who pronounced the death, disposition of the body, and a record of notification of the family. The administrator or administrator’s designee shall include in the record of notification of the family confirmation and written documentation of that

 

 

  • A physician, registered nurse or paramedic may make a determination and pronouncement of death in accordance with N.J.A.C. 13:35-6.2(d) and (e).