SECTION 450:17-7-5. Clinical record content, screening and assessment

(a)   All facilities shall complete a face-to face screening with each individual to determine appropriateness of admission.

(b)   The CMHC shall document the face-to-face screening between the potential consumer and the CMHC including how the consumer was assisted to identify goals, how the consumer received integrated screening to identify both immediate and ongoing needs and how the consumer was assisted to determine appropriateness of admission, and/or to access other appropriate services.

(c)   Upon determination of appropriate admission, consumer demographic information shall be collected.

(d)   All programs shall complete a psychological-social assessment which gathers sufficient information to assist the consumer in developing an individualized service plan.

(e)   The CMHC shall have policy and procedures that stipulate content required for items (c) and (d).

(f)   An assessment update, to include date, identifying information, source of information, present needs, present life situation, current level of functioning, and what consumer wants in terms of service, is acceptable only on re-admissions within one (1) year of previous admission.

(g)   Compliance with 450:450:17-7-5 shall be determined by a review of the following: psychological-social assessment instruments; consumer records; case management assessments; interviews with staff and consumers; policies and procedures and other facility documentation.

[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 22 Ok Reg 960, eff 7-1-05; Amended at 23 Ok Reg 1421, eff 7-1-06; Amended at 24 Ok Reg 2563, eff 7-12-07; Amended at 27 Ok Reg 2216, eff 7-11-10; Amended at 33 Ok Reg 964, eff 9-1-16; Amended at 34 Ok Reg 1777, eff 10-1-17]