New York Codes, Rules and Regulations
Title 10 - DEPARTMENT OF HEALTH
Chapter V - Medical Facilities
Subchapter C - State Hospital Code
Article 6 - Treatment Center and Diagnostic Center Operation
Part 759 - Adult Day Health Care Services For Registrants With Aids and other high-need populations
Section 759.9 - Medical record system
Universal Citation: 10 NY Comp Codes Rules and Regs ยง 759.9
Current through Register Vol. 46, No. 39, September 25, 2024
The operator must:
(a) maintain a medical record system that contains a record, including a current comprehensive care plan for each registrant, in accordance with accepted professional standards of practice and the medical records system section of this Title. Each registrant's medical record shall contain, as a minimum:
(1)
identification and admission information, including:
(i) all details of the referral and
registration;
(ii) identification
of next of kin, family and sponsor;
(iii) the person or persons to be contacted
in the event of emergency;
(iv)
accident and incident reports;
(v)
non-medical correspondence and papers pertinent to the registrant's
participation in the program; and
(vi) a fiscal record including copies of all
agreements or contracts;
(2) documentation of medical examinations,
progress notes and discharge summaries; and
(3) all other pertinent information related
to the resident's care including record of attendance;
(b) develop and implement policies and procedures to ensure the confidentiality of all medical records.
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