New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIV - Office for People With Developmental Disabilities › Part 676 - Diagnostic and Research Clinics › Section 676.10 - Recordkeeping

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
OPWDD.
The diagnostic and research clinic shall maintain a
				  comprehensive record of each person referred and admitted to the clinic. Each
				  record shall be organized in the manner and contain the information specified
				  by OPWDD for inclusion. Each individual's record shall contain the following
				  types of information:
(1) person
				identification information, including, if applicable, a Medicaid or Medicare
				number, a developmental disabilities information survey profile,
				etc.;
(2) information regarding the
				person's medical and developmental history;
(3) copies of previous diagnoses or tentative
				diagnoses, assessments, progress notes, and, if possible, copies of individual
				program plans or service plans previously developed for the person at other
				programs or agencies;
(4)
				descriptions of treatment and medications previously administered;
(5) name and address of person or
				organization referring the individual to the diagnostic and research clinic and
				reason for such referral;
(6)
				criteria for admission eligibility and itemized lists of diagnostic and
				evaluation services, specialized clinical laboratory services, need for
				residential services and any other optional services required by the person.
				This section of the record shall include written authorizations by clinicians
				for diagnosis, evaluation or clinical laboratory services;
(7) authorizations signed by the clinic's
				attending physicians and/or clinicians who have designated that the person
				receive other optional services in addition to the core or optional services
				initially authorized by the admission committee;
(8) written authorizations by a physician or
				other clinician to admit a person for short-term residential care; such record
				should include date of admission, projected date of discharge, actual date of
				discharge, services received while in the residential unit, and a report of any
				significant occurrence in the life and experience of the person while staying
				at the clinic;
(9) discipline
				specific diagnostic summaries, evaluations and findings and recommendations for
				services; and
(10) minutes and
				decisions made by the interdisciplinary team including copies of the
				individual's recommended treatment plan in which at least the following shall
				be stated:
(i) primary and secondary
				diagnoses;
(ii) integrated
				evaluations, and statements concerning the severity of the
				disability;
(iii) prioritized
				long-range goals and short-range objectives that are matched to prioritized
				needs and areas of behavioral and medical deficits;
(iv) services and methods of interventions
				recommended to address the person's deficits; and
(v) recommendations for follow-up visits
				and/or recommendations to have the person receive services at other specialized
				diagnostic and evaluation programs;
(11) minutes of conferences conducted between
				clinical staff and the person and/or his or her correspondent in which the
				clinician's findings and recommendations are explained and discussed;
(12) minutes of conferences, meetings,
				discussions, etc., between clinical staff at the diagnostic and research clinic
				and the referring agency and/or the agency who has been or will be delivering
				the recommended services to the person; and
(13) notes and correspondence between clinic
				staff and referring agents, family, family physicians, advocacy organization,
				and programs providing services to the person or programs considering the
				person for admission.