Okla. Admin. Code § 317:30-5-278.1

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

Section 317:30-5-278.1 - Documentation of records

All psychological services will be reflected by documentation in the patient records.

(1) All assessment, testing, and treatment services/units billed must include the following:

(A) date;

(B) start and stop time for each session/unit billed;

(C) signature of the provider;

(D) credentials of provider;

(E) specific problem(s), goals and/or objectives addressed;

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

(G) progress made toward goals and objectives;

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

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

(2) For each Group psychotherapy session, a separate list of participants must be maintained.

(3) Psychological testing will be documented for each date of service performed which should include at a minimum, the objectives for testing, the tests administered, the results/conclusions and interpretation of the tests, and recommendations for treatment and/or care based on testing results and analysis.

Okla. Admin. Code § 317:30-5-278.1

Added at 18 Ok Reg 2959, eff 5-17-01 (emergency); Added at 19 Ok Reg 1067, eff 5-13-02; Amended at 23 Ok Reg 2554, eff 6-25-06; Amended at 26 Ok Reg 2111, eff 6-25-09