N.Y. Comp. Codes R. & Regs. tit. 14 § 587.18

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

Section 587.18 - Case records

(a) There shall be a complete case record maintained for each person admitted into an outpatient program. Such case record shall be maintained in accordance with recognized and acceptable principles of recordkeeping as follows:

(1) case record entries shall be made in nonerasable ink or typewriter;

(2) case records shall be legible;

(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.

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

(1) recipient identifying information and history;

(2) preadmission screening notes, as appropriate;

(3) diagnosis;

(4) assessment of the recipient's psychiatric, physical, social, and/or psychiatric rehabilitation needs;

(5) reports of all mental and physical diagnostic exams, assessments, tests, and consultations;

(6) the treatment plan or psychiatric rehabilitation service plan;

(7) record and date of all on-site and off-site face to face contacts with the recipient, the type of service provided and the duration of contact;

(8) dated progress notes which relate to goals and objectives of treatment;

(9) dated progress notes which relate to significant events and/or untoward incidents;

(10) periodic treatment plan reviews;

(11) dated and signed records of all medications prescribed;

(12) discharge summary;

(13) referrals to other programs and services;

(14) consent forms;

(15) record of contacts with collaterals; and

(16) discharge plan.

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

(d) When a recipient is transferred between programs offered by the same provider, a consolidated record format which follows the recipient may be used.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 587.18

Amended, New York State Register, Volume XXXVI, Issue 22, effective 6/4/2014