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 for review and inspection by Department of Health staff or designees.  The records must contain at a minimum:

• Personal data, including identification of the resident's next of kin, family or resident's representative, legal representative, if any, and the name and address of the person or persons to be contacted in the event of an emergency; 
• Medical evaluations and other medical information; 
• Health care proxy or other advance directives, if applicable;
• Pre-admission evaluation and subsequent functional and social evaluations;
• Individualized service plans; 
• Medication assistance record; and 
• Case management notes which include details of referrals, service coordination and such other correspondence and papers as are available to document the activities undertaken to meet the resident’s needs.