New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIII - Office of Mental Health
Part 594 - Operation Of Licensed Housing Programs For Children And Adolescents With Serious Emotional Disturbances
Section 594.15 - Case records and reports
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 594.15
Current through Register Vol. 46, No. 39, September 25, 2024
(a) There shall be a complete case record maintained for each resident. Such case record shall be maintained in accordance with recognized and acceptable principles of recordkeeping as follows:
(1) case record
entries shall be in nonerasable ink or typewriter;
(2) case records shall be legible;
(3) case records shall be periodically
reviewed for quality and completeness; and
(4) case records shall be dated and signed by
appropriate staff.
(b) The case record shall be available to all staff of the program who are participating in the provision of services to the resident and shall include the following information:
(1) resident
identifying information and history;
(2) preadmission screening notes, as
appropriate;
(3)
diagnosis;
(4) assessment of the
resident's psychiatric, physical, social and educational/vocational
needs;
(5) reports of appropriate
and necessary mental and physical diagnostic exams, assessments, tests and
consultations;
(6) the
individualized written service plan;
(7) dated progress notes which relate to
goals and objectives of service provision in accordance with periodic
reviews;
(8) notes which relate to
significant events and/or untoward incidents;
(9) periodic service plan reviews;
(10) discharge planning summary;
(11) referrals to other programs and
services;
(12) consent
forms;
(13) discharge plan;
and
(14) for CREDIT programs, the
case record shall also include a Wellness Self Management Plan specifying
techniques for maintaining a positive body image.
(c) Statistical information shall be prepared and maintained as may be necessary for the effective operation of the program, and as may be required by the Office of Mental Health.
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