SECTION 317:30-5-209. Documentation

  All services must be reflected by documentation in the patient records. All assessment and treatment services must include the following:

(1)   date;

(2)   start and stop time for each timed treatment session;

(3)   signature of the service provider;

(4)   credentials of service provider;

(5)   documentation of the referral source;

(6)   problems(s), goals and/or objectives identified on the treatment plan;

(7)   methods used to address the problem(s), goals and objectives;

(8)   progress made toward goals and objectives;

(9)   patient response to the session or intervention; and

(10)   any new problem(s), goals and/or objectives identified during the session.

[Source: Added at 25 Ok Reg 423, eff 11-1-07 (emergency); Added at 25 Ok Reg 1161, eff 5-25-08]