SECTION 450:17-3-21. Integrated screening and assessment services

(a)   CMHC policy and procedure shall require that a screening of each consumer's service needs is completed in a timely manner. An integrated screening should be welcoming and culturally appropriate, include screening of whether the consumer is a risk to self or others, including suicide risk factors, as well as maximize recognition of the prevalence of co-occurring disorders among those who typically present for services at a Community Mental Health Center.

(b)   Upon determination of appropriate admission, a consumer assessment shall be completed by a LBHP or licensure candidate and shall include, but not be limited to, the following information:

(1)   Behavioral, including mental health and addictive disorders as well as the following;

(A)   presenting problem and current symptomology;

(B)   previous treatment history;

(C)   current and past psychotropic and addiction medications, including name, dosage and frequency; and

(D)   Family history of mental health and other addictive disorders.

(2)   Emotional, including issues related to past or current trauma and domestic violence;

(3)   Physical/medical, including;

(A)   health history and current biomedical conditions and complications;

(B)   current and past physical health medications, including name, dosage and frequency.

(4)   Social and recreational, including;

(A)   family and other relationships;

(B)   recovery and community supports;

(C)   leisure and wellness activities; and

(D)   culture, including traditions and values.

(5)   Vocational, including;

(A)   educational attainment, difficulties, and history;

(B)   current or previous military service including discharge status; and

(C)   current and desired employment status.

(c)   The consumer and family as appropriate shall be an active participant(s) in the screening and assessment process.

(d)   The CMHC shall have policy and procedures specific to each program service which dictate timeframes by when assessments must be completed and documented. In the event the consumer is not admitted and as a result the assessment is not included in the clinical record, the policy shall specify how screening and assessment information is maintained and stored.

(e)   Compliance with 450:17-3-21 shall be determined by a review of clinical records, and policy and procedures.

[Source: Added at 13 Ok Reg 2741, eff 7-1-96; Amended at 18 Ok Reg 2658, eff 7-1-01; Amended at 19 Ok Reg 2333, eff 7-1-02; Amended at 20 Ok Reg 1303, eff 7-1-03; Amended at 23 Ok Reg 1421, eff 7-1-06; Amended at 24 Ok Reg 2563, eff 7-12-07; Amended at 26 Ok Reg 2675, eff 7-25-09; Amended at 34 Ok Reg 1777, eff 10-1-17; Amended at 35 Ok Reg 1809, eff 10-1-18]