New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIII - Office of Mental Health
Part 595 - Operation Of Residential Programs For Adults
Section 595.14 - Case records and reports
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 595.14
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 psychiatric rehabilitative
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) documentation of the
type of service provided, the date it was provided, its duration and the name
of the person rendering the service;
(9) notes which relate to significant events
and/or untoward incidents;
(10)
periodic service plan reviews;
(11)
discharge planning summary;
(12)
referrals to other programs and services;
(13) consent forms;
(14) discharge plan; and
(15) residency agreement.
(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.
Disclaimer: These regulations may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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