Current through Register Vol. 46, No. 39, September 25, 2024
(a) An integrated
services provider shall maintain a record of all integrated care services
provided to an individual who is admitted to and treated by such provider, and
this may be accomplished via a single integrated record for the
individual.
(b) Regardless of form
or format, each integrated care services program shall establish a
recordkeeping system which is maintained in accordance with recognized and
accepted principles of recordkeeping.
(c) Each integrated care services program
shall designate a staff member who has overall supervisory responsibility for
the recordkeeping system. The recordkeeping supervisor shall ensure that:
(1) the integrated care record for each
patient contains and centralizes all physical and behavioral health information
which identifies the patient, justifies the treatment and documents the results
of such treatment;
(2) entries in
the integrated care record are current, legible to individuals other than the
author, are authenticated with a signature of the person making the entry,
date, and time;
(3) handwritten
entries must be made in permanent, non-erasable blue or black ink or
typed;
(4) information contained in
the integrated care record is securely maintained, kept confidential,
safeguarded from environmental damage, and made available only to authorized
persons who have a need to know the information; and
(5) when a patient is treated by an outside
provider, and that treatment is relevant to the patient's care, a clinical
summary or other pertinent documents are obtained to promote continuity of
care; if documents cannot be obtained, the reason must be noted in the
integrated care record.
(d) The integrated care record format shall
facilitate the ability to record the following information for each patient, as
relevant:
(1) patient basic demographic
information;
(2) patient physical
health and behavioral health history:
(i)
Physical health information
(a) physical
examination reports;
(b) diagnosis
or medical impression;
(c)
diagnostic procedures/tests reports;
(d) medical orders and anesthesia
record;
(e) immunization and drug
history; and
(f) notation of
allergic or adverse reactions to medications;
(ii) Mental health information
(a) diagnosis or diagnostic
impression;
(b) psychosocial
assessment; and
(c) mental health
treatment history;
(iii)
Substance use information
(a) diagnosis or
diagnostic impression;
(b)
substance use disorder assessment, including the use of tobacco;
(c) the impact of the use of substances, on
self and significant others; and
(d) substance use disorder treatment history
including prior periods of sustained recovery and how such recovery was
supported;
(3)
admission note;
(4) assessment of
the patient's goals regarding basic treatment goals and needs;
(5) treatment plan and applicable
reviews;
(6) dated progress notes
that relate to goals and objectives of treatment;
(7) discharge plan;
(8) documentation of the services provided
and any referrals made;
(9)
discharge summary;
(10) dated and
signed records of all medications prescribed by the clinic and other
prescription medications being used by the patient, if applicable;
(11) consent forms, if applicable;
and
(12) record of contacts with
collaterals if applicable.
(e) Patient case records must be retained for
a minimum period of six (6) years from the date of the last service provided to
a patient 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.
(f)
Confidentiality
(1) Notwithstanding any other
New York State regulation, in cases where component providers of an integrated
care services program are governed by different state or federal laws and
regulations protecting clinical records and information, the integrated care
record shall be governed by the state and federal privacy rules and regulations
that give the most protection to the record, unless it is possible to redact
provisions of the record with more protection without compromising the purpose
for which the record is being disclosed.
(2) An integrated care services program
providing substance use disorder services must obtain patient consent prior to
making any disclosures from the integrated care record, unless the disclosure
is authorized as an exception pursuant to federal regulations.
(3) AIDS and HIV information shall only be
disclosed in accordance with Article 27-F of the Public Health
Law.
