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.  More specifically, the records must be complete, accurately documented, readily accessible, and systematically organized.  They should be retained for six years from the date of discharge or death.  For residents who are minors, the records should be kept for three years after the resident reaches the age of majority.

The facility must keep confidential all information contained in the resident’s records regardless of the form or storage method of the records.  The facility must permit each resident to inspect his or her records and obtain copies of such records.  

The clinical records must contain at least the following:

• Sufficient information to identify the resident;
• A record of the resident's comprehensive assessments;
• The plan of care and services provided;
• The results of any preadmission screening conducted by the State;
• Progress notes by all practitioners and professional staff caring for the resident; and
• Reports of all diagnostic tests and results of treatments and procedures ordered for the resident