SECTION 450:17-7-3. Basic requirements

(a)   The CMHC's policies and procedures shall:

(1)   Define the content of the consumer record in accordance with 450:17-7-4 through 17-7-9.

(2)   Define storage, retention and destruction requirements for consumer records. ODMHSAS operated CMHCs shall comply with the Department's Records Disposition Schedule as approved by the Oklahoma Archives and Records Commission.

(3)   Require consumer records be maintained in locked equipment which is kept within a locked room, vehicle, or premise.

(4)   Require legible entries in consumer records, signed with first name or initial and last name of the person making the entry.

(5)   Require the consumer's name be typed or written on each page in the consumer record.

(6)   Require a signed consent for treatment before a consumer is admitted on a voluntary basis.

(7)   Require a signed consent for follow-up before any contact after discharge is made.

(b)   Compliance with 450:17-7-3 shall be determined by a review of the following: facility policy, procedures or operational methods; clinical records; other facility provided documentation; and PI information and reports. A CMHC may propose administrative and clinical efficiencies through a streamlining of the requirements noted in this subchapter if client outcomes are maintained or improved and face-to-face clinical time is able to be increased by proposed reduction in recordkeeping requirements. Such proposal shall be submitted for consideration and approval by the Department.

[Source: Added at 13 Ok Reg 2741, eff 7-1-96; Amended at 17 Ok Reg 2126, eff 7-1-00; 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 27 Ok Reg 2216, eff 7-11-10; Amended at 33 Ok Reg 964, eff 9-1-16]