N.Y. Comp. Codes R. & Regs. tit. 14 § 584.16 - Maintaining Case Records at Residential Treatment Facilities for Children and Youth with Mental Disabilities

This regulation requires that all residential treatment facilities for children and youth with mental disabilities maintain a complete case record for each child.  The regulation states that the facility is required to maintain these case records confidentially, and permits disclosure only in 5 cases:  pursuant to a court order, to a mental health information service, to attorneys representing the child in a proceeding in which the resident’s involuntary admission to the facility is at issue, to physicians and providers of health care and welfare services with the consent of the child, to agencies that need the information to make payments to or on behalf of the residents.  The regulation makes the case record also available to the clinical staff involved in the care and treatment of the child.
 
The regulation further provides a list of 13 items to include in the case record, including but not limited to:  identifying information, source of referral, application for admission, psychiatric/medical assessments, all mental and physical diagnostic reports, treatment plans, progress notes, summaries of treatment plan reviews, medication orders, and discharge summary.  The regulation further specifies what the "initial treatment plan" and "comprehensive treatment plan" should include.