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 include at a minimum the source of referral, documentation of any case conferences, reports of other evaluations and case consultations, medical orders and consent forms.
 
The regulation requires that these facilities maintain all patient records confidentially, and only disclose the information as allowed federal regulations under 42 C.F.R. Part 2.  With respect to medical services, the regulation requires that they all comply with applicable federal and state law, and that they be provided in accordance with a physician’s, physician assistant’s or nurse practitioner’s order.  The regulation requires that the record of a patient participating in more than one chemical dependence service be easily identifiable based on the service s/he is currently enrolled in. The regulation requires that the services report statistical information as required by the office of alcoholism and substance abuse services.