Statutes, codes, and regulations
New York Codes, Rules and Regulations
Title 9 - EXECUTIVE DEPARTMENTSubtitle AA - STATE COMMISSION OF CORRECTIONChapter IV - Minimum Standards And Regulations For Management Of Secure Facilities Operated By The Office Of Children And Family Service
Part 7410 - Health Services
Section 7410.23 - Medical records

N.Y. Comp. Codes R. & Regs. tit. 9 § 7410.23

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Current through Register Vol. 46, No. 41, October 9, 2024
Section 7410.23 - Medical records
(a) A permanent individual medical record shall be established and maintained for every resident.
(b) All health care services provided to residents 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 resident 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) OCFS shall maintain a professional review system which ensures that a representative sample of resident medical records in every facility is periodically reviewed for completeness and for quality of medical care based upon evidence in the medical record.
(f) OCFS shall provide each clinical health services authority with trained staff responsible for resident medical records.
(g) Each clinical health services authority shall maintain a system of storage and identification to ensure the prompt location and retrieval of every resident medical record.
(h) The medical record of every resident transferred between secure facilities shall be forwarded in a confidential manner, consistent with section 2782 of the Public Heath Law, with the resident at the time of transfer to the receiving secure facility. If, due to an emergency situation, it is not possible to forward the medical record at the time of a resident's transfer, such record shall be forwarded to the receiving facility within 24 hours of the time of transfer.
(i) All resident medical records shall be safely and securely retained as required by law.
(j) All resident records shall be confidential and access to them restricted as required by law.

N.Y. Comp. Codes R. & Regs. Tit. 9 § 7410.23

Renumbered from subtitle AA of chapter III New York State Register April 11, 2018/Volume XL, Issue 15, eff. 4/11/2018