Sec. 817.6. Patient records

(a) Case records.

(1) Programs must maintain individual case records for each patient served. Patient records maintained by inpatient services are confidential and may only be disclosed in conformity with Federal regulations regarding the confidentiality of records related to persons receiving treatment for substance use disorder as set forth in 42 Code of Federal Regulations part 2, or other applicable law.

(2) There shall be a single individual record for each person admitted to the program which shall include, at a minimum:

(i) identifying information about the patient and their family;

(ii) the source of referral, date of commencing service and name of primary counselor;

(iii) the admission diagnosis, including chemical dependence-related, medical, and psychiatric diagnoses in official nomenclature with associated diagnostic codes;

(iv) reports of all evaluations performed, including findings and conclusions;

(v) reports of all examinations performed, including but not limited to X-rays, clinical laboratory tests, clinical psychological tests, electroencephalograms, and psychometric tests;

(vi) the written and signed individual treatment plan, including all reviews and updates;

(vii) progress notes informative of the patient's condition and response to treatment, written and signed by staff members;

(viii) summaries of case conferences, treatment plan updates, and special consultations and communications held;

(ix) dated and signed prescriptions or orders for all medications with notation of termination dates;

(x) the discharge and level of care transitions plan;

(xi) any other documents or information regarding the patient's condition, treatment, and results of treatment; and

(xii) signed forms consenting to treatment and for obtaining or releasing confidential information in accordance with 42 Code of Federal Regulations part 2 or other applicable law.

(b) Disclosures.

Disclosure of HIV and AIDS related information contained in a patient's record shall be made in accordance with the article 24 of the Public Health Law, other applicable State and Federal statutes and regulations, and subject to the additional disclosure requirements of 42 Code of Federal Regulations part 2.

(c) Reporting to office.

Statistical information shall be reported to the office as required and on the prescribed forms therefor.