N.Y. Comp. Codes R. & Regs. tit. 14 § 81.8

Current through Register Vol. 46, No. 45, November 2, 2024

Section 81.8 - Records and statistics

(a) Case records.

(1) There shall be an individual record for each person admitted to the school.

(2) Each case record shall include:

(i) legal admission documents;

(ii) identifying information on the individual and his family;

(iii) source of referral, date of commencing service and name of staff member carrying overall responsibility for treatment and care;

(iv) initial, intercurrent and final diagnoses, including psychiatric or mental retardation diagnoses in official terminology;

(v) reports of all diagnostic examinations and evaluations, including findings and conclusions;

(vi) reports of all periodic medical, dental, eye and hearing examinations;

(vii) reports of all special studies performed, including X-rays, clinical laboratory tests, clinical psychological testing, electro-encephalograms, psychometric tests;

(viii) the individual written plan of care, treatment and training (section 81.6[a][2] of this Part) or the program narrative as discussed in section 27.3(f) of this Title for integrated residential communities as defined in section 27.2(g). Integrated residential communities pursuant to section 27.2(g) shall comply with section 27.3(f) and are exempt from the requirements of subparagraphs (a)(2)(ix), (x) and (xii) of this section;

(ix) progress notes written and signed by all staff members having significant participation in the program of treatment and care;

(x) summaries of case conferences and special consultations;

(xi) dated and signed prescriptions or orders for all medications with notation of termination dates;

(xii) a closing summary of the course of treatment and care; and

(xiii) documentation of any referrals to another agency.

(3) Patient records shall be safeguarded for confidentiality and be made accessible only to authorized persons.

(b) Statistical records and reports.

(1) Such statistical information shall be prepared and maintained as may be necessary for optimally effective operation of the school and as may be required by the department.

(2)

(i) Admissions, discharges and other statistical information shall be reported to the department as required and on the forms prescribed therefor.

(ii) Statistical reporting shall be the responsibility of an appropriately qualified employee whose name and title shall be made known to the department.

(3) Summaries of statistical information shall be reviewed at least annually by the governing body.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 81.8