N.Y. Comp. Codes R. & Regs. tit. 14 § 580.9 - Maintaining Records and Statistics at Psychiatric Inpatient Units in General Hospitals

This regulation governs the maintenance of individual records at psychiatric inpatient units in general hospitals.  The regulation requires that the unit maintain an individual record for every admitted person, and that the record include a list of thirteen things, including but not limited to identifying information, legal admission documents, source of referral, initial and final diagnoses, reports of all diagnostic exams, lab reports, plan of treatment, progress notes, signed prescriptions, and closing summaries of the course of treatment.  The regulation requires that these records be safeguarded for confidentiality and that access be limited to authorized persons in compliance with state and federal laws and regulations.
 
The regulation states that statistical reports can be prepared and maintained as required by the office of mental health to ensure effective running of the unit.  The regulation requires that the unit report admissions, discharges and other statistical information to the office of mental health as required and in the format prescribed by the office.  The regulation requires that a qualified employee handle this reporting responsibility and that the governing body review summaries of this statistical information at least once a year.