Statutes, codes, and regulations
New York Codes, Rules and Regulations
Title 9 - EXECUTIVE DEPARTMENTSubtitle AA - STATE COMMISSION OF CORRECTIONChapter VI - Minimum Standards And Regulations For Management Of State Correctional Facilities
Part 7651 - Health Services
Section 7651.19 - Medical records

N.Y. Comp. Codes R. & Regs. tit. 9 § 7651.19

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Current through Register Vol. 46, No. 45, November 2, 2024
Section 7651.19 - Medical records
(a) A permanent individual medical record shall be recorded and maintained for every inmate.
(b) All health care services provided to inmates by facility health care staff or by independent health care providers shall be permanently recorded in the medical record.
(c) Medical records shall contain sufficient information to justify the diagnosis and warrant the treatment and results.
(d) Each inmate's medical history shall be kept current.
(e) Each active inmate medical record shall contain a written, regularly updated list of diagnosed medical problems located at the beginning of the record.
(f) The department shall maintain a professional review system which ensures that a representative sample of inmate medical records in every facility is periodically reviewed for completeness and for quality of medical care based upon evidence in the medical record.
(g) The department shall provide each clinical health services authority with a trained medical records clerk responsible for inmate medical records.
(h) Each clinical health services authority shall maintain a system of storage and identification to ensure the prompt location and retrieval of every inmate medical record.
(i) Consistent with Public Health Law, article 27-F the medical record of every inmate transferred between correctional facilities shall be routinely forwarded with the inmate at the time of transfer to the receiving facility. If, due to an emergency situation, it is not possible to forward the medical record at the time of an inmate's transfer, such record shall be forwarded to the receiving facility within 24 hours of the time of transfer. When an inmate is transferred to a local correctional facility, the transfer of medical records shall be consistent with the requirements of section 601 of the Correction Law.
(j) All inmate medical records shall be safely and securely retained as required by law.
(k) All inmate medical records shall be confidential and access to them restricted as required by law.

N.Y. Comp. Codes R. & Regs. Tit. 9 § 7651.19

Renumbered from subtitle AA of chapter V New York State Register April 11, 2018/Volume XL, Issue 15, eff. 4/11/2018