Section 404.13 - Recordkeeping

404.13 Recordkeeping

(a) An integrated services provider shall maintain a record of all integrated care services provided to an individual who is admitted to and treated by such provider, and this may be accomplished via a single integrated record for the individual.

(b) Regardless of form or format, each integrated care services program shall establish a recordkeeping system which is maintained in accordance with recognized and accepted principles of recordkeeping.

(c) Each integrated care services program shall designate a staff member who has overall supervisory responsibility for the recordkeeping system. The recordkeeping supervisor shall ensure that:

(1) the integrated care record for each patient contains and centralizes all physical and behavioral health information which identifies the patient, justifies the treatment and documents the results of such treatment;

(2) entries in the integrated care record are current, legible to individuals other than the author, are authenticated with a signature of the person making the entry, date, and time;

(3) handwritten entries must be made in permanent, non-erasable blue or black ink or typed;

(4) information contained in the integrated care record is securely maintained, kept confidential, safeguarded from environmental damage, and made available only to authorized persons who have a need to know the information; and

(5) when a patient is treated by an outside provider, and that treatment is relevant to the patient's care, a clinical summary or other pertinent documents are obtained to promote continuity of care; if documents cannot be obtained, the reason must be noted in the integrated care record.

(d) The integrated care record format shall facilitate the ability to record the following information for each patient, as relevant:

(1) patient basic demographic information;

(2) patient physical health and behavioral health history:

(i) Physical health information

(a) physical examination reports;

(b) diagnosis or medical impression;

(c) diagnostic procedures/tests reports;

(d) medical orders and anesthesia record;

(e) immunization and drug history; and

(f) notation of allergic or adverse reactions to medications;

(ii) Mental health information

(a ) diagnosis or diagnostic impression;

(b) psychosocial assessment; and

(c) mental health treatment history;

(iii) Substance use information

(a) diagnosis or diagnostic impression;

(b) substance use disorder assessment, including the use of tobacco;

(c) the impact of the use of substances, on self and significant others; and

(d )substance use disorder treatment history including prior periods of sustained recovery and how such recovery was supported;

(3) admission note;

(4) assessment of the patient's goals regarding basic treatment goals and needs;

(5) treatment plan and applicable reviews;

(6) dated progress notes that relate to goals and objectives of treatment;

(7) discharge plan;

(8) documentation of the services provided and any referrals made;

(9) discharge summary;

(10) dated and signed records of all medications prescribed by the clinic and other prescription medications being used by the patient, if applicable;

(11) consent forms, if applicable; and

(12) record of contacts with collaterals if applicable.

(e) Patient case records must be retained for a minimum period of six (6) years from the date of the last service provided to a patient or, in the case of a minor, for at least six years after the last date of service or three years after he/she reaches majority whichever time period is longer.

(f) Confidentiality

(1) Notwithstanding any other New York State regulation, in cases where component providers of an integrated care services program are governed by different state or federal laws and regulations protecting clinical records and information, the integrated care record shall be governed by the state and federal privacy rules and regulations that give the most protection to the record, unless it is possible to redact provisions of the record with more protection without compromising the purpose for which the record is being disclosed.

(2) An integrated care services program providing substance use disorder services must obtain patient consent prior to making any disclosures from the integrated care record, unless the disclosure is authorized as an exception pursuant to federal regulations.

(3) AIDS and HIV information shall only be disclosed in accordance with Article 27-F of the Public Health Law.

Effective Date: 
Thursday, January 1, 2015
Doc Status: 
Complete