 |
Oklahoma Administrative Code (Last Updated: March 11, 2021) |
 |
TITLE 450. Department of Mental Health and Substance Abuse Services |
|
Chapter 23. Standards and Criteria for Community-Based Structured Crisis Centers |
|
Subchapter 5. CBSCC Clinical Records |
SECTION 450:23-5-5. Health, mental health, substance abuse, and drug history
Latest version.
- (a) A health and drug history shall be completed for each consumer at the time of admission in facility-based crisis stabilization and as soon as practical in the URC. The medical history shall include obtainable information regarding:(1) Name of medication;(2) Strength and dosage of current medication;(3) Length of time patient was on the medication if known;(4) Benefit(s) of medication;(5) Side effects;(6) The prescribing medical professional if known; and(7) Relevant drug history of family members.(b) A mental health history, including symptoms and safety screening, shall be completed for each consumer at the time of admission.(c) A substance abuse history, including checklist for use, abuse, and dependence for common substances (including nicotine and caffeine) and screening for withdrawal risk and IV use shall be completed for each consumer at the time of admission(d) Compliance with 450:23-5-5 shall be determined by a review of clinical records.