Rules and regulations exist governing a New York State nursing home's duties and obligations with regard to producing copies of a nursing home resident's medical and nursing records.
Section 18(2) of the New York Public Health Law (PHL) states that, upon written request, a health care provider shall provide an opportunity, within ten days, for a patient to inspect the patient’s information concerning or relating to the examination or treatment of the patient.
Section 18(1)(b) defines “Health care provider” or “provider” as a “health care facility” or a “health care practitioner” as defined by this subdivision.
Section 18(1) (c) defines “Health care facility” or “facility” as a “hospital as defined in article twenty-eight of this chapter”
Section 2801 defines “Hospital” as “a facility or institution engaged principally in providing services by or under the supervision of a physician or, in the case of a dental clinic or dental dispensary, of a dentist, or, in the case of a midwifery birth center, of a midwife, for the prevention, diagnosis or treatment of human disease, pain, injury, deformity or physical condition, including, but not limited to, a general hospital, public health center, diagnostic center, treatment center, dental clinic, dental dispensary, rehabilitation center other than a facility used solely for vocational rehabilitation, nursing home … .”
In addition to Section 18(2) of the New York Public Health Law (PHL), 10 NYCRR 415.3(c)(iv) mandates that the facility provide the requesting party with the right “to inspect all records including clinical records, pertaining to himself or herself within 24 hours after oral or written request to the facility” and, in addition, to purchase copies with 48 hours of the request.
Moreover, 42 CFR 483.10(g) additionally requires that the facility must provide the records within 24 hours of the request.
Finally, the Rules and Regulations of the Board of Regents concerning professional conduct clearly require your compliance with such request. For your reference, the specific regulation referred to [Chapter 1, Board of Regents, Sec. 2(a)(6)] states:
“Unprofessional conduct shall also include … upon a patient’s written request, failing to make available to a patient … copies of the record required by paragraph 3 of this sub-division (i.e. office records) and copies of the reports, test records, evaluations of x-rays relating to the patient which are in possession or under the control of the licensee.”
Failure to comply with State law and with the Board of Regents Rules and Regulations may be considered misconduct under New York Education Law Sec. 6509.
Examples of portions of the patient’s medical records that may be requested include, but are not limited to, nurse's notes, physician’s orders, medication/treatment administration records (i.e. MARs/TARs), CNA (certified nursing aide) accountability records, Minimum Data Sets (MDS), care plans, risk assessments, discharge notes, transfer records, patient review instruments (PRI), x-ray interpretation, photographs, lab results, physical therapy records, occupational therapy records, social service records, wound sheets, pressure ulcer tracking forms, etc.
In addition, there are explicit rules which prohibit a New York State nursing home from retaliating and/or discriminating against a resident in response to the filing of an action against the nursing home, specifically by way of a Public Health Law § 2801-d action. With respect to the above, PHL § 2801-d(1)(a), which provides that:
No person shall discriminate against any patient of a residential health care facility because such patient, or the patient's legal representative, has brought or caused to be brought any action pursuant to this section, …
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