SECTION 450:17-7-10. Progress Notes

(a)   Progress notes shall chronologically describe the services provided, the consumer's response to the services provided and the consumer's progress in treatment and adhere to the format and content requirements described in the facility policy and procedures.

(b)   Progress notes shall be documented according to the following time frames:

(1)   Outpatient staff must document each visit or transaction, except for assessment completion or service plan development, including missed appointments;

(2)   Community living program staff shall complete a summary note monthly identifying the name of the person served and the day(s) the person received the service;

(3)   Inpatient: nursing service is to document on each shift. Each member of the treatment team shall write a weekly progress note for the first two months and monthly thereafter; and

(4)   PSR staff must maintain a daily, member sign-in/sign-out record of member attendance, and shall write a progress note daily or a summary progress note weekly.

(c)   Compliance with 450:17-7-10 shall be determined by a review of clinical records and policies and procedures.

[Source: Added at 13 Ok Reg 2741, eff 7-1-96; Amended at 16 Ok Reg 1494, eff 7-1-99; 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 25 Ok Reg 2526, eff 7-11-08; Amended at 27 Ok Reg 2216, eff 7-11-10]