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 information required to justify the diagnosis and treatment.  The regulation provides a list of items to be included in the medical record:  identifying information of the person being treated, current diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, description of patients problems and needs, statement of treatment goals and objectives to address these problems and needs including an estimated duration of treatment required and a description of the treatment and prognosis, progress notes, summary of patient’s condition at the time when treatment is completed.