New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XXI - OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES
Part 818 - Chemical Dependence Inpatient Rehabilitation Services
Section 818.6 - Patient Records
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 818.6
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Patient Records.
(1)
Inpatient programs must maintain individual patient records for each patient
served. Patient records maintained by inpatient programs are confidential and
may only be disclosed in accordance 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 patient record for each
person admitted to the inpatient 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/recovery 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 held;
(ix) dated and signed prescriptions or
orders for all medications with notation of termination dates;
(x) the discharge 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.
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