N.Y. Comp. Codes R. & Regs. tit. 14 § 594.15

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

Section 594.15 - Case records and reports

(a) There shall be a complete case record maintained for each resident. Such case record shall be maintained in accordance with recognized and acceptable principles of recordkeeping as follows:

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

(2) case records shall be legible;

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

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

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

(1) resident identifying information and history;

(2) preadmission screening notes, as appropriate;

(3) diagnosis;

(4) assessment of the resident's psychiatric, physical, social and educational/vocational needs;

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

(6) the individualized written service plan;

(7) dated progress notes which relate to goals and objectives of service provision in accordance with periodic reviews;

(8) notes which relate to significant events and/or untoward incidents;

(9) periodic service plan reviews;

(10) discharge planning summary;

(11) referrals to other programs and services;

(12) consent forms;

(13) discharge plan; and

(14) for CREDIT programs, the case record shall also include a Wellness Self Management Plan specifying techniques for maintaining a positive body image.

(c) Statistical information shall be prepared and maintained as may be necessary for the effective operation of the program, and as may be required by the Office of Mental Health.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 594.15