New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIII - Office of Mental Health
Part 599 - Clinic Treatment Programs
Section 599.11 - Case records

Universal Citation: 14 NY Comp Codes Rules and Regs ยง 599.11

Current through Register Vol. 46, No. 39, September 25, 2024

(a) There shall be a complete case record maintained for each person admitted to a Mental Health Outpatient Treatment and Rehabilitative Service program. Such case records shall be maintained in accordance with recognized and accepted principles of recordkeeping as follows:

(1) hard copy case record entries shall be made in non-erasable ink or typed, and shall be legible;

(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; and

(3) all entries in case records shall be dated and signed by appropriate staff.

(b) The case record shall be available to all staff of the Mental Health Outpatient Treatment and Rehabilitative Service program who are participating in the treatment of the individual and shall include the following information:

(1) individual demographics, identifying information, and history;

(2) preadmission screening notes, as appropriate;

(3) admission note;

(4) diagnosis;

(5) assessment of the individual's needs;

(6) reports of all mental and physical diagnostic exams, mental health assessments, screenings, tests, and consultations, including risk assessments, health monitoring, and evaluative reports concerning co-occurring developmental, medical, substance use or educational issues performed by the program;

(7) Treatment Plans;

(8) dated progress notes that relate to goals and objectives of treatment;

(9) dated progress notes that relate to significant events and/or incidents;

(10) treatment plan reviews;

(11) dated and signed records of all medications prescribed by the Mental Health Outpatient Treatment and Rehabilitative Service program; and other prescription medications being used by the individual if known;

(12) discharge plan; and referrals to other programs and services, if applicable;

(13) consent forms, if applicable;

(14) record of contacts with collaterals if applicable; and

(15) discharge summary.

(c) The discharge summary shall be transmitted to the receiving program, where applicable, prior to the arrival of the individual, or within two weeks, whichever comes first. When circumstances interfere with a timely transmittal of the discharge summary, notation shall be made in the record of the reason for delay.

(d) When a n individual is transferred between programs offered by the same provider, a consolidated record format that follows the individual may be used.

(e) Records must be retained for a minimum period of six years from the last date of service and in accordance with Office record retention policy.

(f) Information in Mental Health Outpatient Treatment and Rehabilitative Service program 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 approved local or unified services plan (including programs that receive 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 approved 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 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 redisclosed as permitted by such law or regulation.

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