Okla. Admin. Code § 450:17-5-180

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

Section 450:17-5-180 - Initial assessment, initial care plan, and comprehensive assessment

(a) The initial assessment and the initial care plan must be completed within ten (10) business days after the first contact. The initial care plan must include, at a minimum, the following:

(1) Preliminary diagnoses;

(2) Source of referral;

(3) Reason for seeking care, as stated by the client or other individuals who are significantly involved;

(4) Identification of the client's immediate clinical care needs related to the diagnosis for mental and substance use disorders;

(5) A list of current prescriptions and over-the-counter medications, as well as other substances the client may be taking;

(6) The use of any alcohol and/or other drugs the client may be taking and indications for any current medications;

(7) A summary of previous mental health and substance use disorder treatments, with a focus on which treatments helped and were not helpful;

(8) An assessment of whether the client is a risk to self or to others, including suicide risk factors;

(9) An assessment of the need for medical care (with referral and follow-up as required);

(10) An assessment of whether the client has other concerns for their safety, such as intimate partner violence;

(11) A determination of whether the person presently is or ever has been a member of the U.S. Armed Services;

(12) For children and youth, a determination of whether the person has or has had involvement in government systems, such as child welfare and juvenile justice; and

(13) At least one (1) immediate treatment goal.

(b) A comprehensive assessment is required for all people receiving CCBHC services. Clinicians should use their clinical judgment with respect to the depth of questioning within the assessment so that the assessment actively engages the person receiving services around their presenting concern(s). The assessment should gather the amount of information that is commensurate with the complexity of their specific needs, and prioritize preferences of people receiving services with respect to the depth of assessment and their treatment goals.

(c) A Licensed Behavioral Health Professional (LBHP) or Licensure Candidate, acting within his/her scope of practice requirements, must complete the initial assessment, initial care plan, and comprehensive assessment in accordance with OAC 450:17-3-21 for consumers who have not been assessed by the facility within the past six (6) months.

Okla. Admin. Code § 450:17-5-180

Adopted by Oklahome Register, Volume 33, Issue 23, August 15, 2016, eff. 9/1/2016

Amended by Oklahoma Register, Volume 38, Issue 23, August 16, 2021, eff. 9/15/2021

Amended by Oklahoma Register, Volume 41, Issue 22, August 1, 2024, eff. 9/1/2024