N.Y. Comp. Codes R. & Regs. tit. 14 § 595.14 - Maintaining Case Records at Residential Programs for Adults with Mental Illness

This regulation requires that Residential Programs for Adults with Mental Illness maintain complete case records for each resident.  The regulation sets forth certain principles of recordkeeping for these programs to follow: record entries shall be non-erasable, legible, periodically reviewed for quality, and dated and signed by the appropriate staff. 
 
The regulation further grants access to the staff of the program to the case record, and states that the case record should contain 15 items:  resident identifying information, preadmission notes, diagnosis, assessment of patient's needs, reports of medical exams, individual written service plan, dated progress notes, documentation of service provided, notes on any significant events, periodic reviews of the service plan, discharge planning summary, referrals to other programs, consent forms, discharge plans and residency agreement.  The regulation requires that the programs also maintain statistical information as required by the Office of Mental Health.