SECTION 310:667-35-4. Special requirements - medical records

  In addition to the basic medical record requirements for general medical surgical records, medical records for rehabilitative patients shall include the following:

(1)   The reason for referral or admission to the rehabilitation facility.

(2)   A summary of the patient's clinical condition, functional strengths and limitations, indications and contraindications for specific physical rehabilitation services, and prognosis.

(3)   Initial and comprehensive treatment plans as specified in 310:667-35-3(a)(5). The goals of treatment, any problems that may affect the outcome of rehabilitation, and criteria leading to the discontinuation of services shall be documented.

(4)   Treatment and progress records, with appropriate ongoing assessments as required by the patient's condition. A description of the perception of the patient and family toward, and their involvement in, physical rehabilitation services.

(5)   Assessment of physical rehabilitation achievement and estimates of further rehabilitation potential, entered on a timely basis, which shall be made at least monthly and included in the individualized comprehensive treatment plan.

(6)   A discharge summary that includes the physical rehabilitation achieved, the medications and therapy prescribed at discharge, and recommendations for further rehabilitation.

[Source: Added at 12 Ok Reg 1555, eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95]