N.Y. Comp. Codes R. & Regs. tit. 14 § 600.12

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

Section 600.12 - Case record

(a) There shall be a complete legible case record maintained for each Recipient at a Crisis Stabilization Center.

(b) The case record shall be available to all clinical staff of the Crisis Stabilization Center who are participating in the treatment of the Recipient consistent with 45 C.F.R. Parts 160 and 164 and 42 CFR Part 2.

(c) All Recipients from the Crisis Stabilization Center must have a case record which, at a minimum, includes a presentation note which indicates:

(1) a brief description of the presenting problem, critical needs and overall conditions;

(2) a brief description of the care and treatment required to address the Recipient's needs safely and effectively during the initial period after screening and assessment; and

(3) a brief description of the Crisis Stabilization Center's attempts to contact collaterals.

(d) Case records for Recipients shall include:

(1) Recipient identifying information and available substance use, psychiatric, medical and relevant social history, including the Recipient's residential situation and the details of the circumstances leading to the Recipient's presentation at the Center, and the name of the person or persons who have referred or brought the Recipient to the Center, if any. In the case of Recipients brought to the Center by law enforcement, the officer(s) should be interviewed and identified in the case record;

(2) diagnosis if applicable;

(3) assessment of the Recipient's treatment needs based upon substance use, psychiatric, physical, social and functional evaluations;

(4) individual service plan;

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

(6) progress notes which relate to goals and objectives of treatment and document services provided.

(7) notes which relate to special circumstances and clinically relevant incidents;

(8) dated and signed orders for all medications;

(9) discharge plan, including demonstrated linkages to referrals to other programs and services;

(10) consents as appropriate pursuant to this Part; and

(11) documentation of attempts to contact Collaterals.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 600.12

Adopted New York State Register June 29, 2022/Volume XLIV, Issue 26, eff. 6/13/2022