Patient Records Required by NJ Medicaid

Documenting each patient encounter not only benefits the patient but it is also good preventative medicine for the doctor against claims of professional negligence, violations of professional standards, as well as investigations by government agencies. The position taken by most licensing boards and law enforcement agencies is that if an item or service is not documented in a patient’s medical record “it didn’t happen.” Below we discuss the minimum documentation requirements imposed by New Jersey Medicaid on participating providers.

Initial Patient Encounter

NJ Medicaid imposes certain minimum documentation requirements that must be recorded for the initial visit of a 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).

Established Patient Visits

The regulations provide that the following information be recorded in established patients’ progress notes:

1. The purpose of the visit;
2. The pertinent physical, family and social history obtained;
3. A record of pertinent physical findings, including pertinent negative findings based upon i and ii above;
4. Procedures performed, if any, with results;
5. Laboratory, X-Ray, electrocardiogram (ECG), or any other diagnostic tests ordered, with the results of the tests; and
6. Prognosis and diagnosis.

Irrespective of the status of the patients, the medical necessity of services rendered in order to support the procedure code(s) claimed must be detailed in the physician’s notes.

If you have a question about the New Jersey Medicaid Program, provider enrollment, revalidation or participation or have other legal questions, please contact us here.