New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XXI - OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES
Part 819 - Chemical Dependence Residential Services
Section 819.6 - Record keeping

(a) Substance Use Disorder residential services must maintain individual records for each resident served. These resident records must, at a minimum, include the information required in this Part, as well as the source of referral, documentation of any case conferences or case reviews, reports of other evaluations and case consultations, medical orders, if applicable, and consent forms.

(b) Resident records maintained by substance use disorder residential services are confidential and only may be disclosed consistent with the Health Insurance Portability and Accountability Act (HIPAA) and the federal regulations governing the confidentiality of patient/resident records as set forth in 42 Code of Federal Regulations Part 2 and other applicable law.

(c) Any medical and/or mental health treatments provided, including medications, shall be maintained in accordance with the requirements of federal and state law and approved policies and procedures.

(d) All medical or psychiatric services provided must be provided pursuant to the orders of a physician, physician assistant, or nurse practitioner working within their scope of practice.

(e) In the event that more than one substance use disorder service is offered by a facility, the resident record shall identify the service in which the resident is participating currently.

(f) Statistical information shall be reported to the Office as required and on the prescribed forms therefor.