N.Y. Comp. Codes R. & Regs. tit. 14 § 85.9 - Maintaining Records and Statistics on Persons Admitted to Outpatient Facilities for Mentally Disabled

This regulation requires that outpatient facilities for mentally disabled maintain individual records for each person admitted, and that each record include 11 items, including identifying information about the person, source of referral, initial and final diagnoses, clinical reports, individual written plan of care, dated and signed prescriptions, etc.  The regulation demands that the certificate holder at the facility develop policies and procedures fro recording information about relevant persons not admitted for service such as those on waiting lists or those rejected.  The regulation requires that all patient records be maintained confidentially and allows disclosure only to authorized persons.  The regulation further requires that the facilities maintain statistical records and reports as required by the department of mental hygiene to ensure optimal operation.  The regulation requires that the governing bodies of the facilities review the summaries of statistical reports annually.