New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XXI - OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES
Part 817 - Substance Use Disorder Residential Rehabilitation Services for Youth (RRSY)
Section 817.6 - Patient records
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 817.6
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Patient Records.
(1)
Programs must maintain individual patient records for each patient served.
Patient records are confidential and may only be disclosed in conformity with
federal regulations regarding the confidentiality of records related to persons
receiving treatment for substance use disorder as set forth in 42 Code of
Federal Regulations Part 2, or other applicable state and federal
laws.
(2) There shall be a single
individual record for each person admitted to the program which shall include,
at a minimum:
(i) identifying information
about the patient and their family;
(ii) the source of referral, date of
commencing service and name of primary counselor;
(iii) the admission diagnosis, including
substance use related, medical, and psychiatric diagnoses in official
nomenclature with associated diagnostic codes;
(iv) reports of all evaluations performed,
including findings and conclusions;
(v) reports of all examinations performed,
including but not limited to X-rays, clinical laboratory tests, clinical
psychological tests, electroencephalograms, and psychometric tests;
(vi) the written and signed individual
treatment plan, including all reviews and updates;
(vii) progress notes informative of the
patient's condition and response to treatment, written and signed by staff
members;
(viii) summaries of case
conferences, treatment plan updates, and special consultations and
communications held;
(ix) dated and
signed prescriptions or orders for all medications with notation of termination
dates;
(x) the discharge and level
of care transitions plan;
(xi) any
other documents or information regarding the patient's condition, treatment,
and results of treatment; and
(xii)
signed forms consenting to treatment and for obtaining or releasing
confidential information in accordance with 42 Code of Federal Regulations Part
2 or other applicable law.
(b) Disclosures. Disclosure of HIV related information contained in a patient's record shall be made in accordance with the Article 27f of the Public Health Law, other applicable state and federal statutes and regulations, and subject to the additional disclosure requirements of 42 Code of Federal Regulations Part 2.
(c) Reporting to Office. Statistical information shall be reported to the Office as required and on the prescribed forms therefor.
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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