Current through Register Vol. 46, No. 39, September 25, 2024
(a) There shall
be a complete legible case record maintained for each patient admitted to a
comprehensive psychiatric emergency program.
(b) The case record shall be available to all
clinical staff of the comprehensive psychiatric emergency program who are
participating in the treatment of the patient consistent with 45 C.F.R. parts
160 and 164.
(c) All individuals
receiving services from the comprehensive psychiatric emergency program must
have a case record which, at a minimum, includes a presentation note which
indicates:
(1) a brief description of the
presenting problem, critical needs and overall conditions;
(2) a brief description of the care and
treatment required to safely and effectively address the individual's needs
during the initial period after admission; and
(3) a brief description of the comprehensive
psychiatric emergency program's attempts to contact collaterals.
(d) In addition to the information
called for in subdivision (c) of this section, each case record for individuals
who receive a triage and referral visit, a full emergency visit, or are
admitted to an extended observation bed or receive crisis outreach shall
include:
(a) patient identifying information
and available psychiatric medical and relevant social history, including the
person's residential situation and the details of the circumstances leading to
the individual's presentation at the comprehensive psychiatric emergency
program, and the name of the person or persons who have referred or brought the
individual to the comprehensive psychiatric emergency program, if any. In the
case of individuals brought to the comprehensive psychiatric emergency program
by law enforcement officers, the officers should be interviewed and identified
in the case record;
(b)
diagnosis;
(c) assessment of the
patient's treatment needs based upon psychiatric, physical, social and
functional evaluations; and
(d)
progress notes which relate to goals and objectives of treatment and document
services provided.
(e)
The following information is required for each case record for individuals who
receive a full emergency visit and/or is admitted to an extended observation
bed and may be included in the case record for individuals who receive a triage
and referral visit and/or crisis outreach:
(a)
reports of all mental and physical diagnostic exams, assessments, tests, and
consultations;
(b) notes which
relate to special circumstances and untoward incidents;
(c) dated and signed orders for all
medications;
(d) discharge summary,
including referrals to other programs and services, which must be completed
within five days of discharge and;
(e) documentation of attempts to contact
collaterals.
(f) The case record
shall include documentation of the patient's status pursuant to mental hygiene
law.
