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 to state that all entries in the case record are to be made in non-erasable ink, legibly, and signed and dated by appropriate staff.  The regulation further requires that these records be reviewed for quality and completeness.  With respect to the contents of the case records, the regulation specifies 16 types of information to be included in the case records, including but not limited to:  recipient identifying information, preadmission screening notes, diagnosis, recipient’s psychiatric assessment, reports of mental and physical exams, treatment plan, progress notes, records of prescribed medication, discharge summary, referrals to other programs, and consent forms.  The regulation specifies certain requirements for transmitting discharge summaries to the program receiving the discharged patient.