N.Y. Comp. Codes R. & Regs. Tit. 14 §§ 511-2.9

Current through Register Vol. 46, No. 45, November 2, 2024

Section 511-2.9 - Case Records

(a) The CMHRS Program shall maintain a case record for each child admitted and receiving CMHRS services provided directly and/ or pursuant to formal agreement with a designated provider. In the case of agreements between a CMHRS program and designated provider, the designated provider may also maintain a separate case record for the purposes of quality assurance, monitoring and billing.

(b) The CMHRS program shall ensure proper exchange of information between providers to facilitate coordination of care.

(c) There shall be a complete case record maintained for each child admitted to the program. Such case record shall be maintained in accordance with recognized and acceptable principles of recordkeeping as follows:

(1) Case record entries shall be legible and non-erasable;

(2) Electronic records which use accepted mechanisms for clinician signatures and are maintained in a secure manner, may be utilized. Such records may be kept in lieu of a hard copy case record;

(3) Case records shall be periodically reviewed for quality and completeness; and

(4) All entries in case records shall be dated and signed by appropriate staff.

(d) The case record shall be available to all staff of the CMHRS program who are participating in the treatment of the child and shall include the following information:

(1) Child identifying information and history;

(2) Diagnosis; or symptoms of a mental illness exhibited by the child;

(3) Recommendation for service(s) from a LPHA based on assessment of the child's mental health needs;

(4) Reports obtained of any mental and physical diagnostic exams, assessments, tests, and consultations;

(5) The treatment plan and crisis management plan, if applicable;

(6) Referrals to other programs and services;

(7) Consent forms;

(8) Record and date of contacts with the child, the type of service provided, and the duration of contact;

(9) Record and date of all contacts with collateral providers for coordination of care;

(10) Dated progress notes which relate to goals and objectives of treatment;

(11) Dated progress notes which relate to significant events and/or untoward incidents;

(12) Periodic treatment plan reviews;

(13) Discharge plan; and

(14) Discharge Summary within three business days of discharge.

(i) The discharge summary shall be transmitted to the receiving program, where applicable, prior to the arrival of the child, or within two weeks, whichever comes first.

(ii) When circumstances interfere with a timely transmittal of the discharge summary, notation shall be made in the record of the reason for delay. In such circumstances, a copy of all clinical documentation shall be forwarded to the receiving program, as appropriate, prior to the arrival of the child.

(iii) When a child is transferred between programs offered by the same provider, a consolidated record format that follows the child may be used.

(15) Records must be retained for a minimum period of six years from the date of the last service provided to child or, in the case of a minor, for at least six years after the last date of service or three years after he/she reaches majority whichever time period is longer.

(16) Information in case records that is subject to the confidentiality protections of Mental Hygiene Law section 33.13 may be shared between facilities, agencies, and programs responsible for the provision of services pursuant to an approval local or unified services plan (including programs that received funding from the Office disbursed via a State aid letter); the Office and any of the psychiatric centers and programs that it operates; and facilities, agencies and programs that are not licensed by the Office and are not participants in an approval local or unified services plan, but are responsible for the provision of services to any patient pursuant to a written agreement with the Office as a party, provided, however, if a case record contains HIV or AIDS information that it is protected by Public Health Law Article 27-F, or information provided by a federally-funded alcoholism/substance abuse provider that is protected under 42 CFR part 2, such information shall only be re-disclosed as permitted by such law or regulation.

N.Y. Comp. Codes R. & Regs. Tit. 14 §§ 511-2.9

Adopted New York State Register July 17, 2019/Volume XLI, Issue 29, eff. 7/17/2019