Current through Register Vol. 46, No. 39, September 25, 2024
(a) The CMHRS
Program shall maintain a case record for each child admitted and receiving
CMHRS services provided directly and/ or pursuant to formal agreement with a
designated provider. In the case of agreements between a CMHRS program and
designated provider, the designated provider may also maintain a separate case
record for the purposes of quality assurance, monitoring and billing.
(b) The CMHRS program shall ensure proper
exchange of information between providers to facilitate coordination of
care.
(c) There shall be a complete
case record maintained for each child admitted to the program. Such case record
shall be maintained in accordance with recognized and acceptable principles of
recordkeeping as follows:
(1) Case record
entries shall be legible and non-erasable;
(2) Electronic records which use accepted
mechanisms for clinician signatures and are maintained in a secure manner, may
be utilized. Such records may be kept in lieu of a hard copy case
record;
(3) Case records shall be
periodically reviewed for quality and completeness; and
(4) All entries in case records shall be
dated and signed by appropriate staff.
(d) The case record shall be available to all
staff of the CMHRS program who are participating in the treatment of the child
and shall include the following information:
(1) Child identifying information and
history;
(2) Diagnosis; or symptoms
of a mental illness exhibited by the child;
(3) Recommendation for service(s) from a LPHA
based on assessment of the child's mental health needs;
(4) Reports obtained of any mental and
physical diagnostic exams, assessments, tests, and consultations;
(5) The treatment plan and crisis management
plan, if applicable;
(6) Referrals
to other programs and services;
(7)
Consent forms;
(8) Record and date
of contacts with the child, the type of service provided, and the duration of
contact;
(9) Record and date of all
contacts with collateral providers for coordination of care;
(10) Dated progress notes which relate to
goals and objectives of treatment;
(11) Dated progress notes which relate to
significant events and/or untoward incidents;
(12) Periodic treatment plan
reviews;
(13) Discharge plan;
and
(14) Discharge Summary within
three business days of discharge.
(i) The
discharge summary shall be transmitted to the receiving program, where
applicable, prior to the arrival of the child, or within two weeks, whichever
comes first.
(ii) When
circumstances interfere with a timely transmittal of the discharge summary,
notation shall be made in the record of the reason for delay. In such
circumstances, a copy of all clinical documentation shall be forwarded to the
receiving program, as appropriate, prior to the arrival of the child.
(iii) When a child is transferred
between programs offered by the same provider, a consolidated record format
that follows the child may be used.
(15) Records must be retained for a minimum
period of six years from the date of the last service provided to child 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.
(16) Information in case
records that is subject to the confidentiality protections of Mental Hygiene
Law section
33.13 may
be shared between facilities, agencies, and programs responsible for the
provision of services pursuant to an approval local or unified services plan
(including programs that received funding from the Office disbursed via a State
aid letter); the Office and any of the psychiatric centers and programs that it
operates; and facilities, agencies and programs that are not licensed by the
Office and are not participants in an approval local or unified services plan,
but are responsible for the provision of services to any patient pursuant to a
written agreement with the Office as a party, provided, however, if a case
record contains HIV or AIDS information that it is protected by Public Health
Law Article 27-F, or information provided by a federally-funded
alcoholism/substance abuse provider that is protected under 42 CFR part 2, such
information shall only be re-disclosed as permitted by such law or
regulation.
