SECTION 317:30-5-1046. Documentation of records and records review

(a)   The Organized Health Care Delivery System (OHCDS) and the facilities with whom it contracts must maintain appropriate records system. Current individual plans of care, case files, and progress notes are maintained in the facilities' files during the time the child or youth is receiving services. All services rendered must be reflected by documentation in the case records.

(b)   The Oklahoma Health Care Authority (OHCA) and the Centers for Medicare and Medicaid Services (CMS) may evaluate through inspection or other means, the quality, appropriateness and timeliness of services provided by the OHCDS or facilities with whom it contracts.

(c)   All Residential Behavioral Management Services (RBMS) in group settings must be reflected by documentation in the patients' records. Individual, group, family, and alcohol and other drug counseling and social and basic living skills development services must include all of the following:

(1)   Date;

(2)   Start and stop time for each session;

(3)   Signature of the therapist/staff providing service;

(4)   Credentials of therapist/staff providing service;

(5)   Specific problem(s) addressed (problem must be identified on individualized plan of care);

(6)   Methods used to address problem(s);

(7)   Progress made toward goals;

(8)   Patient response to the session or intervention; and

(9)   Any new problem(s) identified during the session.

[Source: Added at 15 Ok Reg 538, eff 11-5-97 (emergency); Added at 15 Ok Reg 1528, eff 5-11-98; Amended at 18 Ok Reg 492, eff 1-1-01 (emergency); Amended at 18 Ok Reg 1130, eff 5-11-01; Amended at 21 Ok Reg 415, eff 1-1-04 (emergency); Amended at 21 Ok Reg 2230, eff 6-25-04; Amended at 24 Ok Reg 2862, eff 7-1-07 (emergency); Amended at 25 Ok Reg 1200, eff 5-25-08; Amended at 27 Ok Reg 623, eff 1-14-10 through 7-14-10 (emergency); Amended at 36 Ok Reg 908, eff 9-1-19]

Note

EDITOR’S NOTE: This emergency action expired without being superseded by a permanent action. Upon expiration of an emergency amendatory action, the last effective permanent text is reinstated. Therefore, on 7-15-10 (after the 7-14-10 expiration of this emergency action), the text of 317:30-5-1046 reverted back to the permanent text that became effective 5-25-08, as was last published in the 2009 OAC Supplement and republished in the 2010 OAC Supplement and the 2011 and 2016 Editions of the OAC, and remained as such until amended by permanent action on 9-1-19.