N.Y. Comp. Codes R. & Regs. tit. 14 § 580.9

Current through Register Vol. 46, No. 53, December 31, 2024

Section 580.9 - Records and statistics

(a) Case records.

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

(2) Each case record shall include:

(i) legal admission documents;

(ii) identifying information on the individual and their family, and, as applicable, guardian;

(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, alcohol or substance use disorder or intellectual or developmental disability diagnoses in official terminology;

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

(vi) reports of all special studies performed, including X-rays, clinical laboratory tests, developmental and psychological testing, electroencephalograms, psychometric tests;

(vii) record of communication with family, outpatient providers, and other significant sources of collateral information;

(viii) the individual written plan of care, treatment and rehabilitation prepared in accordance with section 580.6(a)(2) of this Part;

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

(x) summaries of case conferences and special consultations;

(xi) notes which relate to special circumstances and untoward incidents including but not limited to, the use of any seclusion or restraints;

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

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

(xiv) autopsy findings if an autopsy is performed;

(xv) documentation of any referrals within the hospital or to another agency; and

(xvi) documentation of voluntary or involuntary status and other information as requested by the office .

(b) individual records shall be safeguarded for confidentiality and accessible only to authorized persons, and shall be otherwise maintained in accordance with applicable State and Federal laws and regulations governing the privacy of individually identifying health information.

(c) Statistical records and reports.

(1) Such statistical and case record information shall be prepared and maintained as may be necessary for optimally effective operation of the unit and as may be required by the office.

(2) Admissions, discharges and other statistical and case record information shall be reported to the office as required and in a form and format designated by the office.

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

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

N.Y. Comp. Codes R. & Regs. Tit. 14 § 580.9

Amended New York State Register December 18, 2024/Volume XLVI, Issue 51, eff. 12/18/2024