N.Y. Comp. Codes R. & Regs. tit. 14 § 823.14 - Maintenance of Records by Outpatient Chemical Dependency Services for Youth

This regulation requires that Outpatient Chemical Dependency Services for Youth or OCDYs maintain individual records for each admitted patients, with each recording containing, at a minimum, the following: 

• patient's name, date of birth, sex, race, marital status and residence
• initial admission evaluation notes and results, including documents stating that patient meets admission criteria, that patient was informed that treatment is voluntary, that for minor patients being treated without parental consent, requirements of § 823.8 have been met, and that patient was given a copy of the program’s rules and regulations
• documentation of comprehensive evaluation including results of physical examination
• individual treatment plan
• discharge plan
• progress notes
• quarterly review notes
• any other reviews or determinations with respect to treatment plan
• documentation of referrals and recommendations, and any coordination between agencies including any incoming and outgoing correspondence about the patient
• results of any urine/breath tests
• notes about disclosure of HIV status
• statement of reasons for discharge or termination
• documentation of communication with patient’s family
• signed releases of information