SECTION 450:23-5-4. Clinical record content, intake and assessment

(a)   The CBSCC shall assess each individual to determine appropriateness of admission. Initial assessments by an LMHP are to be completed on all minors voluntary or involuntary prior to admission.

(b)   Consumer intake information shall contain, but not be limited to the following identification data:

(1)   Consumer name;

(2)   Name and identifying information of the legal guardian(s)

(3)   Home address;

(4)   Telephone number;

(5)   Referral source;

(6)   Reason for referral;

(7)   Significant other to be notified in case of emergency;

(8)   PICIS intake data core content;

(9)   Presenting problem and disposition;

(10)   A record of pertinent information regarding adverse reactions to drugs, drug allergies, or sensitivities shall be obtained during intake and kept in a highly visible location in or on the record; and

(11)   Screening for co-occurring disorders, trauma, and homelessness, medical and legal issues.

(c)   Consumer assessment information for consumers admitted to facility-based crisis stabilization shall be completed within 72 hours of admission. Assessment information for consumers in a URC, if applicable, shall be completed within twelve (12) hours of arrival.

(1)   Integrated mental health and substance abuse psychosocial evaluation that minimally addresses:

(A)   The consumer's strengths and abilities to be considered during community re-entry;

(B)   Economic, vocational, educational, social, family and spiritual issues as indicated; and

(C)   An initial discharge plan.

(2)   Interpretive summary of relevant assessment findings that results in the development of an intervention plan addressing mental health, substance use disorder, and other related issues contributing to the crisis;

(3)   An integrated intervention plan that minimally addresses the consumer's:

(A)   Presenting crisis situation that incorporates the identified problem(s);

(B)   Strengths and abilities;

(C)   Needs and preferences; and

(D)   Goals and objectives.

(d)   Compliance with 450:23-5-4 shall be determined by a review of the following: intake assessment instruments and other intake documents of the CBSCC; clinical records; and, other agency documentation of intake materials or requirements.

[Source: Added at 18 Ok Reg 531, eff 10-13-00 (emergency); Added at 18 Ok Reg 2690, eff 7-1-01; Amended at 19 Ok Reg 1443, eff 7-1-02; Amended at 20 Ok Reg 1324, eff 7-1-03; Amended at 23 Ok Reg 1436, eff 7-1-06; Amended at 25 Ok Reg 1404, eff 7-1-08; Amended at 31 Ok Reg 2034, eff 10-1-14]