N.Y. Comp. Codes R. & Regs. tit. 18, § 428.5 – Progress notes (record of service provision).

(a) Progress notes must begin on the case initiation date as defined in section 428.2(a) of this Part or upon receipt of a report of suspected abuse or maltreatment for child protective service cases, and must continue until the case is closed to all services. Progress notes must be made as contemporaneously as possible with the occurrence of the event or the receipt of the information which is to be recorded.
(b) Each progress note entry must include the date of the entry, the date of the event, and the name or initials of the author and person making the entry.
(c) Progress notes must include, but are not limited to:
1. (1) descriptions of contacts with children and parent(s) receiving services, including missed or cancelled appointments, and the reasons therefor;
2. (2) actions taken in the investigation or family assessment response for a reported case of child abuse or maltreatment, including emergency and/or controlling interventions taken, and descriptions of collateral contacts and other activities relating to the collecting of information needed to formulate an assessment and/or assist with making a determination regarding the report of abuse or maltreatment, and descriptions of family and collateral contacts and other activities relating to the provision of a family assessment response; provided, however, the name or other information identifying the reporter and/or the source of a report of suspected child abuse or maltreatment, as well as the agency, institution, organization, and/or program with which such person(s) is associated, must be recorded in the manner specified by OCFS;
3. (3) efforts made to engage the family members in the development of the service plan or the completion of a family led assessment guide, their level or degree of participation in the process and the family and children's reactions to services;
4. (4) referrals and communications with other service providers involved in the case, and information received from specialized rehabilitative and supportive service providers concerning casework contact activities with a child and/or family receiving preventive and/or protective services;
5. (5) referrals and communications with the local probation department regarding a child in the case;
6. (6) description of contacts with educational/vocational personnel on behalf of the child, including, but not limited to, contacts made with school personnel in accordance with sections 430.11(c)(1)(i) and 430.12(c)(4) of this Title;
7. (7) court hearings or other legal activities;
8. (8) significant events such as births, marriages, and divorces;
9. (9) documentation of caseworker/supervisor conferences, including a description of the nature of the discussions and any required follow-up activities; and
10. (10) for children not residing with a parent who are in foster care or an alternative placement setting, progress notes, as applicable, must also include:
  1. (i) casework contacts with child's parent(s), guardian, and/or relatives, the child and the child's day-to-day caretaker(s) including casework contacts required in accordance with section 441.21 of this Title;
  2. (ii) descriptions of activities related to medical and dental examinations required on a regularly scheduled basis, including the initial medical examination, and any significant results, diagnosis, referrals and prescribed medications arising from such medical and dental examinations in accordance with section 441.22 of this Title;
  3. (iii) descriptions of parental and/or guardian visits with a child, and any missed visits and the reasons therefor;
  4. (iv) descriptions of other visits with the child, including but not limited to visits with siblings and/or half-siblings not placed with the child, potential permanency resources and any other persons of significance to the child;
  5. (v) chronological documentation of diligent efforts, as required under section 430.12 of this Title, by an authorized agency to assist, develop and encourage a meaningful relationship between the parent(s) or the guardian and the child;
  6. (vi) efforts by parent(s) or guardian to provide an adequate home and provide parental care for the child, or when it is determined that permanency for a child cannot be achieved within the child's own family, discussions between the parent(s) and the authorized agency regarding the pursuit of adoption or another permanency planning goal for the child;
  7. (vii) documentation that the parent(s) or guardian were advised of the possible consequences if a child remains in foster care for 15 of the most recent 22 months, and of discussions with the parent(s) or guardian regarding the possible deleterious effects of foster care on the child and the child's need for permanency;
  8. (viii) any information acquired about an absent or non-respondent parent that is in addition to information recorded pursuant to section 428.4(c)(1) of this Part, the results of an investigation into the location of any relatives, including grandparents of a child subject to article 10 of the Family Court Act or section 384-a of the Social Services Law, and the efforts to identify and provide notification to grandparents and other adult relatives in accordance with the requirements of section 430.11(c)(4) of this Title;
  9. (ix) a description of the reasonable efforts made to finalize the child's permanency plan, including, but not limited to, where the permanency goal is other than the return of the child to the parent, identification of in-State and out-of-state placement options; and
  10. (x) documentation of the case consultation(s) held for each child subject to the provisions of article 10-A of the Family Court Act and section 428.9 of this Part in preparation for each permanency hearing;
11. (11) for children in foster care with certified or approved foster parent(s):
  1. (i) documentation that the foster parent(s) have been informed of the visiting plan for the child's parent(s), guardian(s), siblings or half-siblings, or others for whom a visiting plan with the child exists;
  2. (ii) documentation that the foster parent(s) or prospective foster parent(s) have been asked whether they will accept a sibling group, if appropriate;
  3. (iii) documentation that the foster parent(s) have been provided with information on the existence and location of all siblings or half-siblings of any child placed with them;
  4. (iv) documentation that the foster parent(s) have been apprised of any special needs that the foster child has and the available supports and services to address the special needs; and
  5. (v) documentation that the foster parent(s) have been informed that diligent efforts will be made to facilitate regular biweekly visitation or communication between minor siblings or half-siblings who have been placed apart, unless such contact would be contrary to the health, safety or welfare of one or more of the children or unless the lack of geographic proximity precludes visitation;
12. (12) for children in foster care placed with relative foster parent(s) whose permanency plan is placement with such relative(s) and receipt of kinship guardianship assistance payments:
  1. (i) the steps taken to determine that it is not appropriate for the child to return home or be adopted;
  2. (ii) the reasons for any separation of siblings during placement;
  3. (iii) the reasons why a permanent placement with a fit and willing relative through a kinship guardianship assistance arrangement is in the child's best interests, including the compelling reasons for determining that the return home of the child and the adoption of the child are not in the best interests of the child and are not appropriate permanency goals;
  4. (iv) the ways in which the child meets the eligibility requirements for a kinship guardianship assistance payment;
  5. (v) the efforts made to discuss adoption by the child's relative foster parent as a more permanent alternative to legal guardianship and, in the case of a relative foster parent who has chosen not to pursue adoption, documentation of the reasons therefore;
  6. (vi) the efforts made to discuss with the child's parent or parents the kinship guardianship assistance arrangement, or the reasons why the efforts were not made; and
  7. (vii) the steps taken to hold age appropriate consultation with the child regarding the kinship guardianship arrangement, including the consultation conducted with a child who is 14 years of age or older and the steps taken to secure the consent of a child who is 18 years of age or older to the kinship guardianship arrangement.
13. (13) for children in foster care with a permanency planning goal of another planned living arrangement with a permanency resource:
  1. (i) the intensive, ongoing and unsuccessful efforts to return the child home or to secure a placement for the child with a fit and willing relative, including adult siblings, a legal guardian or legal custodian, or an adoptive parent, including efforts made that utilize technology, including social media, to locate family members of the child;
  2. (ii) the child’s foster home or child care facility in which the child is placed is following the reasonable and prudent parent standard set forth in section 441.25 of this Title; and
  3. (iii) the child has regular, ongoing opportunities to engage in age or developmentally appropriate activities, including by consulting with the child in an age-appropriate manner about the opportunities to participate in such activities.
(d) Progress notes need not include clinical notes, daily logs or other written material created by service providers who act in roles other than caseworker, child protective services monitor, case planner or case manager.