N.Y. Comp. Codes R. & Regs. tit. 14 § 590.12 - Maintaining Case Records for Patients Admitted to Comprehensive Psychiatric Emergency Programs

This regulation requires that all Comprehensive Psychiatric Emergency Programs maintain complete legible case records for each admitted patient, and permits the clinical staff of these programs to access the case records.  With respect to the contents of the case records, the regulation requires that the case records for admitted patients include the following information:

• Brief description of the problem patient is presenting with
• Brief description of care and treatment required during initial period after admission

With respect to the case records for individuals who receive an emergency visit, or are admitted for extended observation or receive crisis outreach services or interim crisis services or crisis residential services, the regulation requires that they include the following in addition to the two items required above:

• Patient identifying information and all available psychiatric medical and relevant social history, name of the person or persons who brought the patient to the program
• Diagnosis
• Assessment of patient’s treatment needs
• Reports of mental and physical diagnostic exams and consultations
• Progress notes
• Notes of any special circumstances or untoward incidents
• Discharge summary, including referrals to other programs or services
• Description of any services provided in the emergency room, extended observation beds and crisis residential services, and by crisis outreach teams