Okla. Admin. Code § 317:30-5-745

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

Section 317:30-5-745 - Documentation of records

Providers must maintain an appropriate records system. Current individual plans of care, case files, and progress notes are maintained in the provider's files during the time the member is receiving services. All services must be reflected by documentation in the records. Documentation of services must include all of the following:

(1) The date the service was provided;

(2) The beginning and ending time the service was provided;

(3) A description of the member's response to the service;

(4) The type of service provided (individual, group, or family session; group rehabilitative treatment; social skills (re)development; basic living skills (re)development; crisis behavior management and redirection; or discharge planning); and

(5) The dated signature with credentials of the person providing the service. If the service is performed by a licensure candidate, it must be countersigned by the licensed behavioral health professional (LBHP) who is responsible for the member's care. Refer to Oklahoma Administrative Code (OAC) 317:30-5-742.2. (2)(A).

Okla. Admin. Code § 317:30-5-745

Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff 7-27-95; Amended at 17 Ok Reg 2402, eff 6-26-00; Amended at 20 Ok Reg 523, eff 12-1-02 (emergency); Amended at 20 Ok Reg 1216, eff 5-27-03; Amended at 23 Ok Reg 2566, eff 6-25-06; Amended at 27 Ok Reg 1360, eff 4-21-10 (emergency); Amended at 28 Ok Reg 1419, eff 6-25-11

Amended by Oklahoma Register, Volume 37, Issue 24, September 1, 2020, eff. 9/14/2020