New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter IV - Regulation And Quality Control
Subchapter D - Operation Of Facilities
Part 85 - Operation Of Outpatient Facilities For The Mentally Disabled
Section 85.9 - Records and statistics
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 85.9
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Case records.
(1) There shall be an individual
record for each person admitted to the facility.
(2) Each case record shall include:
(i) Identifying information about the person
served and his family,
(ii) Source
of referral, date of commencing service and name of staff member carrying
overall responsibility for treatment and care,
(iii) Initial, intercurrent and final
diagnoses including psychiatric, mental retardation or medical diagnoses in
official terminology,
(iv) Reports
of all diagnostic examinations and evaluations including findings and
conclusions,
(v) Reports of all
special studies performed including X-rays, clinical laboratory tests, clinical
psychological testing, electro-encephalograms or psychometric tests,
(vi) The individual written plan of care,
treatment, and rehabilitation (85.6 [b] above),
(vii) Progress notes written and signed by
all staff members having significant participation in the program of treatment
and care.
(viii) Summaries of case
conferences and special consultations,
(ix) Dated and signed prescriptions or orders
for all medications with notation of termination dates,
(x) A closing summary of the course of
treatment and care, and
(xi)
Documentation of any referrals to another agency.
(3) The certificate holder shall develop
policies and procedures for recording information about persons not admitted
for service such as persons on waiting lists, family members of persons served
and persons whose applications for service are rejected by the
facility.
(4) Patient records shall
be safeguarded for confidentiality and be accessible only to authorized
persons.
(b) Statistical records and reports.
(1) Such statistical
information shall be prepared and maintained as may be necessary for optimally
effective operation of the facility and as may be required by the
department.
(2)
(i) Admissions and discharges, and other
statistical information, shall be reported to the department as required and on
the forms prescribed therefor.
(ii)
Statistical reporting shall be the responsibility of an appropriately qualified
employee whose name and title shall be made known to the department.
(3) Summaries of statistical
information shall be reviewed at least annually by the governing
body.
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