N.Y. Public Health Law § 2899-j: Medical record documentation requirements

§ 2899-j. Medical record documentation requirements. An attending

physician shall document or file the following in the patient's medical

record:

1. the dates of all oral requests by the patient for medication under

this article;

2. the written request by the patient for medication under this

article, including the declaration of witnesses and interpreter's

declaration, if applicable;

3. the attending physician's diagnosis and prognosis, determination of

decision-making capacity, and determination that the patient is acting

voluntarily, of the patient's own volition and without coercion, and has

made an informed decision;

4. written determination of decision-making capacity under section

twenty-eight hundred ninety-nine-i of this article; and

5. a note by the attending physician indicating that all requirements

under this article have been met and indicating the steps taken to carry

out the request, including a notation of the medication prescribed or

ordered.