New York Codes, Rules and Regulations
Title 10 - DEPARTMENT OF HEALTH
Chapter V - Medical Facilities
Subchapter A - Medical Facilities-minimum Standards
Article 6 - Adult Day Health Care in Residential Health Care Facilities
Part 425 - Adult Day Health Care
Section 425.21 - Clinical records
Current through Register Vol. 46, No. 39, September 25, 2024
The operator must:
(a) provide a clinical record for each registrant in accordance with the clinical records requirements of section 415.22 of this Subchapter;
(b) ensure that all reports and information pertaining to registrant care and planning are entered promptly;
(c) ensure that all entries are dated and authenticated by the person making the entry or ordering the services;
(d) ensure that all clinical records for registrants referred by a managed care plan are made available to the referring managed care plan ;
(e) ensure that the record is kept in a place convenient for use by authorized staff; and
(f) retain intact clinical records and all other records of registrants and keep them readily accessible in a safe and secure place. Such records shall be retained safely and securely for a period of six years following discharge or cessation of operation of services. In the case of a minor, retention shall be for three years after reaching majority (18 years of age).
