N.Y. Comp. Codes R. & Regs. tit. 14, § 595.14 – Case records and reports.

(a) There shall be a complete case record maintained for each resident. Such case record shall be maintained in accordance with recognized and acceptable principles of recordkeeping as follows:
1. (1) case record entries shall be in nonerasable ink or typewriter;
2. (2) case records shall be legible;
3. (3) case records shall be periodically reviewed for quality and completeness; and
4. (4) case records shall be dated and signed by appropriate staff.
(b) The case record shall be available to all staff of the program who are participating in the provision of services to the resident and shall include the following information:
1. (1) resident identifying information and history;
2. (2) preadmission screening notes, as appropriate;
3. (3) diagnosis;
4. (4) assessment of the resident's psychiatric, physical, social and psychiatric rehabilitative needs;
5. (5) reports of appropriate and necessary mental and physical diagnostic exams, assessments, tests and consultations;
6. (6) the individualized written service plan;
7. (7) dated progress notes which relate to goals and objectives of service provision in accordance with periodic reviews;
8. (8) documentation of the type of service provided, the date it was provided, its duration and the name of the person rendering the service;
9. (9) notes which relate to significant events and/or untoward incidents;
10. (10) periodic service plan reviews;
11. (11) discharge planning summary;
12. (12) referrals to other programs and services;
13. (13) consent forms;
14. (14) discharge plan; and
15. (15) residency agreement.
(c) Statistical information shall be prepared and maintained as may be necessary for the effective operation of the program, and as may be required by the Office of Mental Health.