SECTION 317:30-5-283. Documentation of records

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

[Source: Added at 27 Ok Reg 1676, eff 7-10-10 (emergency); Added at 28 Ok Reg 1483, eff 6-25-11]