MEDICAL RECORDS                                                                                     35-02-005

DOCUMENTATION

POLICY STATEMENT.

The Division of Veterans Healthcare Services (DVHS) requires that each of the New Jersey Veterans Memorial Homes (VMH) establish a uniform documentation system that incorporates a requirement that all clinical notes be written in accordance with the Standards of Practice outlined in the State Operations Manual 483.20(a) through 483.20(m) inclusive.
 

PURPOSE.

This policy and procedure serves to ensure that each of the New Jersey Veterans Memorial Homes implements a uniform documentation system that ensures all documentation is timely, and reflects quality care that meets or exceeds the New Jersey Department of Health and Senior Services and the U.S. Department of Veterans Affairs standards.

PROCEDURE.

1. All Clinical Notes provided by providers of service (all disciplines) will be written in accordance with the Standards of Practice outlined in the State Operations Manual 483.20(a) through 483.20(m) inclusive.

Revised:   July 2007
Revised:   April 2010

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