N.Y. Comp. Codes R. & Regs. tit. 9 § 7310.11

Current through Register Vol. 46, No. 43, October 23, 2024

Section 7310.11 - Medical records

(a) A permanent individual medical record shall be established and maintained for every youth.

(b) All health care services provided to youth by facility health care staff or by independent health care providers shall be recorded in the medical record.

(c) Medical records shall contain sufficient information to justify the diagnosis and warrant the treatment and results.

(d) Each active youth medical record shall contain a current medical history and a written, regularly updated list of diagnosed medical problems located at the beginning of the record.

(e) Each facility shall maintain a system of storage and identification to ensure the prompt location and retrieval of every youth medical record.

(f) The medical record of every youth transferred to another facility, a facility operated or certified by OCFS, or a facility operated by the Department of Corrections and Community Supervision (DOCCS), shall be forwarded in a confidential manner, consistent with section 2782 of the Public Heath Law, with the youth at the time of transfer to the receiving facility. If, due to an emergency, it is not possible to forward the medical record at the time of a youth's transfer, such record shall be forwarded to the receiving facility within 24 hours of the time of transfer.

(g) All youth medical records shall be safely and securely retained as required by law.

(h) All youth records shall be confidential, and access restricted as required by law.

N.Y. Comp. Codes R. & Regs. Tit. 9 § 7310.11

Adopted New York State Register September 26, 2018/Volume XL, Issue 39, eff. 9/26/2018