Okla. Admin. Code § 317:30-5-560.2

Current through Vol. 42, No. 4, November 1, 2024

Section 317:30-5-560.2 - Record documentation

(a) The treatment plan must be updated and signed by the attending physician [medical doctor (MD), or doctor of osteopathy, (DO)], a physician assistant (PA), or advanced practice registered nurse (APRN) at least annually.

(b) Copies of the attending physician's orders and, at a minimum, the last thirty (30) days of medical records for the actual care provided must be maintained and include the following:

(1) The beginning and ending time of the care and must be signed by the person providing care;

(2) The nurse's credentials;

(3) All provisions of the treatment plan, such as vital signs, medication administration, glucose/neuro checks, vital signs, respiratory assessments, and all applicable treatments must be documented; and

(4) Meet the record retention requirements set forth in Oklahoma Administrative Code (OAC) 317:30-3-15.

Okla. Admin. Code § 317:30-5-560.2

Added at 23 Ok Reg 33, eff 8-1-05 (emergency); Added at 23 Ok Reg 1364, eff 5-25-06; Amended at 24 Ok Reg 333, eff 12-1-06 (emergency); Amended at 24 Ok Reg 930, eff 5-11-07

Amended by Oklahoma Register, Volume 39, Issue 24, September 1, 2022, eff. 9/12/2022