SECTION 317:30-5-278.1. Documentation of records

  All psychological services will be reflected by documentation in the patient records.

(1)   All assessment, testing, and treatment services/units billed must include the following:

(A)   date;

(B)   start and stop time for each session/unit billed;

(C)   signature of the provider;

(D)   credentials of provider;

(E)   specific problem(s), goals and/or objectives addressed;

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

(G)   progress made toward goals and objectives;

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

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

(2)   For each Group psychotherapy session, a separate list of participants must be maintained.

(3)   Psychological testing will be documented for each date of service performed which should include at a minimum, the objectives for testing, the tests administered, the results/conclusions and interpretation of the tests, and recommendations for treatment and/or care based on testing results and analysis.

[Source: Added at 18 Ok Reg 2959, eff 5-17-01 (emergency); Added at 19 Ok Reg 1067, eff 5-13-02; Amended at 23 Ok Reg 2554, eff 6-25-06; Amended at 26 Ok Reg 2111, eff 6-25-09]