N.Y. Comp. Codes R. & Regs. tit. 14 § 818.5 - Recordkeeping at Chemical Dependency Inpatient Rehabilitation Services

This regulation requires that inpatient rehabilitation services maintain individual case records for each patient, and sets forth a list of 12 items that must be included in this patient record:  identifying information; source of referral date of commencing service, name of primary counselor; admission diagnosis; reports of all evaluations; reports of all examinations; written and signed individual treatment plan; progress notes written and signed by staff members; summaries of case conferences, treatment plan updates and special consultations; dated and signed prescriptions; discharge plan; any other documents regarding condition, treatment and results of treatment; and signed consent forms for obtaining and releasing confidential information pursuant to 42 C.F.R. Part 2.
 
The regulation requires that these facilities maintain all patient records confidentially, and only disclose the information as allowed federal regulations under 42 C.F.R. Part 2.  With respect to medical services, the regulation requires that they all comply with applicable federal and state law, and that they be provided in accordance with a physician’s, physician assistant’s or nurse practitioner’s order.  The regulation requires that the record of a patient participating in more than one chemical dependence service be easily identifiable based on the service s/he is currently enrolled in.
 
The regulation only allows disclosure of HIV/AIDS related information in accordance with state and federal laws and regulations. The regulation requires that the services report statistical information as required by the office of alcoholism and substance abuse services.