Section 85.29 - Maintenance of medical records

85.29 Maintenance of medical records.

(a) Private practicing psychiatrists shall maintain medical records containing information sufficient to justify the diagnosis and warrant the treatment of each medical assistance patient served.

(b) As part of this documentation, each medical record shall include:

(1) identifying information about the person treated;

(2) current diagnosis as contained in an approved nomenclature manual such as the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, 1980 (copies are available from the publisher, American Psychiatric Association, 1700 18th Street, N.W., Washington, DC 20009) or the International Classification of Diseases, 9th revision, Clinical Modification, 1978 (copies are available from the publisher, Commission on Professional and Hospital Activities, 1968 Green Road, Ann Arbor, MI 48105). Both publications are available for inspection and copying at the offices of the records access officer of the Department of Health, Corning Tower, Empire State Plaza, Albany, NY;

(3) a description of the patient's problems, strengths, conditions, disabilities and needs;

(4) a statement of the goals and objectives of treatment to address the patient's problems, disabilities and needs, including an estimate of the duration of the patient's need for treatment, a description of the proposed treatment and prognosis;

(5) progress notes providing a chronological description of the patient's progress in relation to the goals and objectives of the established plan of treatment; and

(6) a summary of the patient's condition and disposition when treatment is completed or terminated.

(c) Patient medical records shall be retained in accordance with requirements contained in Social Services regulations (18 NYCRR 540.7).
 

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