New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIII - Office of Mental Health
Part 582 - Operation Of Hospitals For Persons With Mental Illness
Section 582.9 - Records and statistics

Universal Citation: 14 NY Comp Codes Rules and Regs ยง 582.9

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 hospital.

(2) Each case record shall include:
(i) legal admission documents;

(ii) identifying information on the individual and his family;

(iii) source of referral, date of commencing service and name of staff member carrying overall responsibility for treatment and care;

(iv) initial, intercurrent and final diagnoses including psychiatric, alcohol or substance abuse disorder, or mental retardation or developmental disability diagnoses in official terminology;

(v) reports of all diagnostic examinations and evaluations, including findings and conclusions;

(vi) reports of all special studies performed, including X-ray, clinical laboratory tests, clinical psychological testing, electroencephalograms, and psychometric tests;

(vii) the individual written plan of care, treatment and rehabilitation prepared in accordance with section 582.6(a)(2) of this Part;

(viii) progress notes written, dated, and signed by all staff members having significant participation in the program of treatment and care;

(ix) summaries of case conferences and special consultations;

(x) dated and signed prescriptions or orders for all medications, withnotation of termination dates;

(xi) a closing summary of the course of treatment and care;

(xii) autopsy findings if an autopsy is performed; and

(xiii) documentation of any referrals to another agency.

(b) Patient records shall be safeguarded for confidentiality and be accessible only to authorized persons and shall be otherwise maintained in accordance with applicable State and Federal laws and regulations governing the privacy of individually identifying health information.

(c) Statistical records and reports.

(1) Such statistical information shall be prepared and maintained as may be necessary for optimally effective operation of the hospital, and as may be required by the office.

(2) Admissions, discharges and other statistical information shall be reported to the office as required and in a form and format designated by the office. Statistical reporting shall be the responsibility of an appropriately qualified employee, whose name and title shall be made known to the office.

(3) Summaries of statistical information shall be reviewed at least annually by the governing body.

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