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Oklahoma Administrative Code (Last Updated: March 11, 2021) |
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TITLE 450. Department of Mental Health and Substance Abuse Services |
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Chapter 18. Standards and Criteria for Substance Related and Addictive Disorder Treatment Services |
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Subchapter 7. Facility Clinical records |
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Part 1. RECORD SYSTEM |
SECTION 450:18-7-1.1. Consumer record system
Latest version.
- (a) Each facility shall maintain an organized system for the content, confidentiality, storage retention, and disposition of consumer case records.(b) The facility shall have written policies and procedures concerning consumer records which define required documentation within the case record.(c) Consumer records shall be contained within equipment which shall be maintained under locked and secured measures.(d) The facility shall maintain identification and filing systems which enable prompt record location and accessibility by the service providers.(e) Consumer records shall be maintained in the facility where the individual is being treated or served. In the case of temporary office space and in-home treatment services, records may be maintained in the main (permanent) office and transported in secured lock boxes or vehicle trunks to and from temporary offices and homes, when necessary. Consumer records may be permanently maintained at the facility's administrative offices; however, a working copy of the consumer record for the purposes of documentation and review of services provided must be maintained at the site in which the consumer is receiving treatment.(f) The facility shall have policies which govern the storage, retention, and disposition of consumer case records, including electronic records. These policies shall be compatible with protection of consumer's rights against confidential information disclosure at a later date. ODMHSAS operated facilities shall comply with Records Disposition Schedule 82-17 as approved by the Oklahoma Archives and Records Commission.(g) Compliance with 450:18-7-1.1 may be determined by a review of policies and procedures, treatment records, performance improvement guidelines, interviews with staff, and other facility documentation.