N.Y. Comp. Codes R. & Regs. Tit. 10 § 415.22 - Clinical records
(a) The facility
shall maintain clinical records for each resident in accordance with accepted
professional standards and practice. The records shall be:
(1) complete;
(2) accurately documented;
(3) readily accessible; and
(4) systematically organized.
(b) Clinical records shall be
retained for six years from the date of discharge or death or for residents who
are minors, for three years after the resident reaches the age of majority
(18).
(c) The facility shall
safeguard clinical record information against loss, destruction, or unauthorized
use.
(d) The facility shall keep
confidential all information contained in the resident's records, regardless of
the form or storage method of the records, except when release is required by:
(1) transfer to another health care
institution;
(2) law; or
(3) the resident.
(e) The facility shall permit each resident to
inspect his or her records and obtain copies of such records in accordance with
the provisions of section
415.3(c)(1)(iv)
of this Part.
(f) The clinical record
shall contain:
(1) sufficient information to
identify the resident;
(2) a record
of the resident's comprehensive assessments;
(3) the plan of care and services
provided;
(4) the results of any
preadmission screening conducted by the State;
(5) progress notes by all practitioners and
professional staff caring for the resident; and
(6) reports of all diagnostic tests and results
of treatments and procedures ordered for the resident.
Notes
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