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Medical Records Collection, Retention, and Access in New York

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Public homes,1 Shared health facilities,2 facilities that care for persons with developmental disabilities,3 long term care facilities,4 residential care facilities,5 assisted living facilities,6 and adult care facilities must maintain medical records.7

New York requires medical records to contain the following information: (1) health care proxies;8 (2) the consent and revocation of consent to withhold or withdraw life-sustaining treatment;9 (3) the issuance and revocation of do not resuscitate orders;10 (4) a determination that a patient lacks capacity to make treatment decisions;11 (5) confidential HIV information;12 (6) the results of Hepatitis B surface antigen testing performed on pregnant women;13 (7) the names of individuals that bring a person to a hospital because there is a substantial risk they will harm themselves or others;14 and (8) the provision of the mental hygiene law that authorizes an individual’s admission to a facility.15

New York gives patients the right to access their medical records.16 Providers must permit such access within 10 days of receiving a written request for access.17

Hospitals must maintain medical records in accordance with statutory standards. These standards include the requirement that hospitals establish a recordkeeping department and that they maintain records in a secure and confidential manner.18 Additionally, hospitals must keep records of inspection reports.19

New York requires controlled substance records and prescription information to be maintained for a minimum of five years.20

 

Footnotes

  • 1. NY SOC SERV § 195.
  • 2. NY PUB HEALTH § 4710.
  • 3. N.Y. Mental Hyg. Law § 33.03; N.Y. Mental Hyg. Law § 33.13.
  • 4. N.Y. COMP. CODES R. & REGS. TIT. 10, § 1001.12.
  • 5. N.Y. COMP. CODES R. & REGS. TIT. 10, § 415.22.
  • 6. NY PUB HEALTH § 4657.
  • 7. NY SOC SERV § 461-c.
  • 8. NY PUB HEALTH § 2984.
  • 9. NY PUB HEALTH § 2994-f; NY PUB HEALTH § 2994-j.
  • 10. NY PUB HEALTH § 2964; NY PUB HEALTH § 2965; NY PUB HEALTH § 2967; NY PUB HEALTH § 2969; NY PUB HEALTH § 2994-d; NY PUB HEALTH § 2994-I; NY PUB HEALTH § 2994-dd.
  • 11. NY PUB HEALTH § 2963; NY PUB HEALTH § 2983; NY PUB HEALTH § 2994-c.
  • 12. NY PUB HEALTH § 2782.
  • 13. NY PUB HEALTH § 2500-e.
  • 14. NY MENT HYG § 9.39.
  • 15. NY MENT HYG § 9.03.
  • 16. N.Y. Mental Hyg. Law § 33.16; NY PUB HEALTH § 2803-C.
  • 17. NY PUB HEALTH § 18.
  • 18. N.Y. COMP. CODES R. & REGS. TIT. 10, § 405.10.
  • 19. NY PUB HEALTH § 2805-G.
  • 20. NY PUB HEALTH § 3370.

 

Medical Records Collection, Retention, and Access in New York

Subtopic Statute/Regulation Description
Medical Records Collection, Retention, and Access N.Y. EDUC. LAW § 6530 - Definitions of professional misconduct Physicians may be found guilty of professional misconduct under many instances, including: ·        ...
N.Y. Comp. Codes R. & Regs. tit. 10 § 50-4.5 - Intra-Agency (DoH) Disposition of Personal Health-Related Information This regulation requires that all documents containing personal health-related information be disposed in a way that ensures confidentiality. ...
N.Y. Comp. Codes R. & Regs. tit. 10 § 58-1.11 - Reports and Records at Clinical Laboratories This regulation requires that, when requested, a laboratory submit reports containing information and data related to its technical operation, and...
N.Y. Comp. Codes R. & Regs. tit. 10 § 58-2.10 - Required Reports and Confidentiality at Blood Banks This regulation requires that blood banks and institutions using the product to keep complete and accurate records of blood, blood components and...
N.Y. Comp. Codes R. & Regs. tit. 10 § 58-5.8 - Required Records at Hematopoietic Progenitor Cell Banks This regulation requires that hematopoietic progenitor cell procurement services maintain complete records of all such cells released for...
N.Y. Comp. Codes R. & Regs. tit. 10 § 69-4.17 - Procedural Safeguards for Early Intervention Program This regulation enforces various procedural safeguards to ensure the running of the Early Intervention Program.  The regulation requires that...
N.Y. Comp. Codes R. & Regs. tit. 10 § 69-4.26 - Content and Retention of Child Records Collected Under the Early Intervention Program Municipalities are required to maintain a record for each child referred to the early intervention program, which is to be kept confidential as per...
N.Y. Comp. Codes R. & Regs. tit. 10 § 85.29 - Maintenance of Records by Psychiatrists Treating Patients Seeking Medical Assistance for the Needy This regulation requires that private practicing psychiatrist maintain medical records for each medical assistance patient that contain all the...
N.Y. Comp. Codes R. & Regs. tit. 14 § 22.2 - Service of Legal Process on Patients Admitted to Mental Health Facilities This regulation governs the service of process upon patients admitted in mental health facilities.  The regulation prohibits the director of a...
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...
N.Y. Comp. Codes R. & Regs. tit. 14 § 582.9 - Maintaining Records and Statistics at Hospitals for Persons with Mental Illnesses This regulation governs the maintenance of individual records at hospitals for persons with mental illnesses.  The regulation requires that the...
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...
N.Y. Comp. Codes R. & Regs. tit. 14 § 587.18 - Maintaining Case Records for Patients at Outpatient Programs for Mental Illness This regulation requires that all outpatient programs for mental illness maintain a complete case record for each admitted person, and then goes on...
N.Y. Comp. Codes R. & Regs. tit. 14 § 590.12 - Maintaining Case Records for Patients Admitted to Comprehensive Psychiatric Emergency Programs This regulation requires that all Comprehensive Psychiatric Emergency Programs maintain complete legible case records for each admitted patient, and...
N.Y. Comp. Codes R. & Regs. tit. 14 § 594.15 - Maintaining Case Records at Licensed Housing Programs for Children and Adolescents with Serious Emotional Disturbances This regulation requires that Licensed Housing Programs for Children and Adolescents with Serious Emotional Disturbances maintain complete case...
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...
N.Y. Comp. Codes R. & Regs. tit. 14 § 818.5 - Recordkeeping at Chemical Dependency Inpatient Rehabilitation Services This regulation requires that inpatient rehabilitation services maintain individual case records for each patient, and sets forth a list of 12 items...
N.Y. Comp. Codes R. & Regs. tit. 14 § 819.5 - Recordkeeping at Chemical Dependence Residential Services This regulation requires that chemical dependence residential services maintain individual case records for each patient, and that these records...
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...
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...
N.Y. Comp. Codes R. & Regs. tit. 18 § 354.1 - Maintaining Case Records for Applicant/Recipient of Public Assistance This regulation requires that a case record be maintained for every applicant or recipient of public assistance, and defines a case record as all...
N.Y. Comp. Codes R. & Regs. tit. 18 § 354.2 - Use of Case Records of Applicant/Recipient of Public Assistance This regulation states that the case record should present a clear account of the district’s provision of assistance and the services provided...
N.Y. Comp. Codes R. & Regs. tit. 18 § 485.11 - Records and Reports Maintained by Operator of Adult-Care Facility The regulation requires that operators of adult-care facilities maintain records and reports as specified by the department of health, and that these...
N.Y. Pub. Health Law § 2571 - Examination of Children Upon Admission to Children's Institutions This law requires that the administrative officers in charge of admission of children into children’s institutions inquire into whether a child...
N.Y. Soc. Serv. § 373-a - Medical Histories of Children to be Placed for Adoption or Foster Care This regulation requires that authorized agencies provide the medical history of children legally freed for adoption and children to be placed in...
Right to access to medical records (Access by representative or other person authorized by the patient through informed consent; copying fees, or other requirements (e.g., requirement to give patient access in electronic format)) Confidentiality and Disclosure Requirements for Confidential HIV Information – N.Y. Pub. Health Law § 2782 Persons that validly obtain confidential HIV information about a “protected individual” may only disclose the information as follows:...
Maintenance and Confidentiality of Clinical Patient Records – N.Y. Mental Hyg. Law § 33.13 Each facility licensed or operated by the office for people with developmental disabilities must maintain a clinical record for each patient or...
Medical Records Requirements in Hospitals – N.Y. Comp. Codes R. & Regs. tit. 10 § 405.10 Hospitals must have a department that has administrative responsibility for medical records. An accurate, clear, and comprehensive medical record...
Medical Records Requirements in Long Term Care Facilities – N.Y. Comp. Codes R. & Regs. tit. 10, § 1001.12 The operator of a long term care facility must maintain complete, accurate, and current personal records for each resident which must be available...
Medical Records Requirements in Residential Care Facilities – N.Y. Comp. Codes R. & Regs. tit. 10 § 415.22 A residential care facility must maintain clinical records for each resident in accordance with accepted professional standards and practice. ...
N.Y. Pub. Health Law § 2994-d - Requirements for Health Care Decisions Made for Adult Patients by Surrogates Surrogate decision makers have “the right to receive medical information and medical records necessary to make informed decisions about the...
Patient Rights in Medical Facilities – N.Y. Pub. Health Law § 2803-c A copy of the rights and responsibilities of all patients must be posted conspicuously in a public place in every hospital, nursing home, and...
Quality of Care Requirements for Shared Health Facilities – N.Y. Pub. Health Law § 4710 Shared health facilities must take the following actions in order “to ensure quality, continuity and proper coordination of medical care:...
Requirements for Access to Clinical Records – N.Y. Mental Hyg. Law § 33.16 Any provider of services to persons with mental illness or developmental disabilities must provide a patient or client with access to his clinical...
Requirements for Release of Medical Records – N.Y. Pub. Health Law § 17 Upon the written request of any competent patient, parent or guardian, a physician or hospital must release and deliver copies of all x-rays, medical...
Rights and Duties of Health Care Agents – N.Y. Pub. Health Law § 2982 Rights and Duties of Health Care Agents A health care agent is an adult who has been given the authority to make health care decisions on behalf of...
Content of medical record Determination of Capacity to Make a Decision Regarding Cardiopulmonary Resuscitation – N.Y. Pub. Health Law § 2963 Attending physicians must determine “to a reasonable degree of medical certainty” whether an adult patient lacks capacity to make a...
Determination of Lack of Capacity to Make Health Care Decisions for the Purpose of Empowering Agent – N.Y. Pub. Health Law § 2983 An attending physician that determines, “to a reasonable degree of medical certainty”, that a principle lacks the capacity to make health...
Inclusion of Health Care Proxy in the Medical Record – N.Y. Pub. Health Law § 2984 Inclusion of Health Care Proxy in the Medical Record This section of the law discusses a health care provider’s obligations with respect to...
Managing a Nonhospital Order Not to Resuscitate – N.Y. Pub. Health Law § 2994-dd Non-hospital do not resuscitate orders (DNRs) direct emergency personnel, hospice personnel, and hospital emergency services personnel to withhold...
N.Y. Pub. Health Law § 2994-c - Requirements for the Determination of Incapacity An attending physician will determine whether an adult patient lacks capacity to make medical decisions.    A patient’s incapacity to...
Obligations of Attending Physician – N.Y. Pub. Health Law § 2994-f Attending physicians must review the medical basis for a decision to withdraw or withhold life-sustaining treatment and either implement or object to...
Requirements for Admission to a Hospital – N.Y. Mental Hyg. Law § 9.03 Requirements for Emergency Admissions for Immediate Observation, Care and Treatment Article 9 of New York’s Mental Hygiene Law is a set of laws...
Requirements for Adult Care Facility Resident Care, Services and Charges – N.Y. Soc. Serv. Law § 461-c Persons must provide an adult care facility with a medical report upon their admission to such a facility. The report must state that a “...
Requirements for Blood Tests for Hepatitis B and Follow-Up Care for Pregnant Women – N.Y. Pub. Health Law § 2500-e Physicians or other practitioners must “prominently” record Hepatitis B surface antigen test results in a pregnant woman’s medical...
Requirements for Decision-making by an Adult with Capacity – N.Y. Pub. Health Law § 2964 Adults with capacity may make consent to a do not resuscitate order (DNR) orally or in writing.  A patient in a hospital may give their oral...
Requirements for Decision-Making on Behalf of a Minor Patient – N.Y. Pub. Health Law § 2967 A parent or legal guardian may make consent to a do not resuscitate order (DNR) on behalf of minor child if a physician determines that (1) the child...
Requirements for Emergency Admissions for Immediate Observation, Care, and Treatment – N.Y. Mental Hyg. Law § 9.39 Requirements for Emergency Admissions for Immediate Observation, Care and Treatment Article 9 of New York’s Mental Hygiene Law is a set of laws...
Requirements for Quality of Care and Treatment Services for the Mentally Disabled – N.Y. Mental Hyg. Law § 33.03 The director of a facility that provides services to the mentally disabled must require the following: Annual re-examination and evaluation of...
Requirements for Recording the Identification of Veterans and Spouses – N.Y. Pub. Health Law § 2805-o Every nursing home and residential health care facility must keep and maintain accurate records identifying veterans and their spouses residing...
Requirements for Residency Admission in Assisted Living Facilities – N.Y. Pub. Health Law § 4657 Assisted living operators must evaluate prospective residents, with a tool developed by the department, to determine whether admission to the...
Requirements for Revocation of Consent to Order Not to Resuscitate – N.Y. Pub. Health Law § 2969 A patient may revoke their do not resuscitate order (DNR) at any time by expressing their intent to any physician or nurse in the hospital.  A...
Requirements for Surrogate Decision-Making – N.Y. Pub. Health Law § 2965 A surrogate may make consent to a do not resuscitate order (DNR) on behalf of an adult that lacks capacity if (1) the patient has a terminal...
Revocation of consent – N.Y. Pub. Health Law § 2994-j Patients, surrogates, and guardians may revoke their consent to withhold or withdraw life-sustaining treatment at any time. Upon receiving notice of...
Specific Policies for Orders Not to Resuscitate – N.Y. Pub. Health Law § 2994-i A do not resuscitate order (“DNR”) must be documented in a patient’s medical record. DNRs should not be construed to authorize the...
Required maintenance of medical records Laboratories' Duty to Report Communicable Diseases – N.Y. Pub. Health Law § 2102 Laboratories that detect communicable diseases while conducting an exam must report the exam results and relevant facts to the same health official...
N.Y. Pub. Health Law § 3370 - Requirements for Preservation and Inspection of Records Controlled substance records and prescription information must be kept, unless specified otherwise, for at least five years following the date of the...
Requirements for Maintenance of Hospital Financial and Inspection Reports – N.Y. Pub. Health Law § 2805-g Every hospital must maintain, as public information available for public inspection, records containing copies of all inspection reports pertaining...
Destruction, storage and filing of medical records (Cross reference with Security of Health Information) Medical Records Requirements in Hospitals – N.Y. Comp. Codes R. & Regs. tit. 10 § 405.10 Hospitals must have a department that has administrative responsibility for medical records. An accurate, clear, and comprehensive medical record...
Controlled substances records Regulations for Substance Abuse Treatment Records – N.Y. Mental Hyg. Law § 22.05 Substance abuse treatment information is confidential and privileged to the patient, and may only be disclosed in accordance with federal and state...
Click on the individual state law in the table above to see our summary of the individual law.


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