Okla. Admin. Code § 317:30-5-283

Current through Vol. 42, No. 3, October 15, 2024

Section 317:30-5-283 - Documentation of records

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

Okla. Admin. Code § 317:30-5-283

Added at 27 Ok Reg 1676, eff 7-10-10 (emergency); Added at 28 Ok Reg 1483, eff 6-25-11