Okla. Admin. Code § 317:30-5-209

Current through Vol. 41, No. 19, June 17, 2024

Section 317:30-5-209 - Documentation

All services must be reflected by documentation in the patient records. All assessment and treatment services must include the following:

(1) date;

(2) start and stop time for each timed treatment session;

(3) signature of the service provider;

(4) credentials of service provider;

(5) documentation of the referral source;

(6) problems(s), goals and/or objectives identified on the treatment plan;

(7) methods used to address the problem(s), goals and objectives;

(8) progress made toward goals and objectives;

(9) patient response to the session or intervention; and

(10) any new problem(s), goals and/or objectives identified during the session.

Okla. Admin. Code § 317:30-5-209

Added at 25 Ok Reg 423, eff 11-1-07 (emergency); Added at 25 Ok Reg 1161, eff 5-25-08