SECTION 450:23-5-6. Progress notes

(a)   The CBSCC shall have a policy and procedure mandating the chronological documentation of progress notes for consumers admitted to facility-based crisis stabilization.

(b)   Progress notes shall minimally address the following:

(1)   Person(s) to whom services were rendered;

(2)   Activities and services provided and as they relate to the goals and objectives of the intervention plan, including ongoing reference to the intervention plan;

(3)   Documentation of the progress or lack of progress in crisis resolution as defined in the intervention plan;

(4)   Documentation of the intervention plan's implementation, including consumer activities and services;

(5)   The consumer's current status;

(6)   Documentation of the consumer's response to intervention services, changes in behavior and mood, and outcome of intervention services;

(7)   Plans for continuing therapy or for discharge, whichever is appropriate; and

(b)   Progress notes shall be documented according to the following time frames:

(1)   Intervention team shall document progress notes daily; and

(2)   Nursing service shall document progress notes on each shift.

(d)   Compliance with 450:23-5-6 shall be determined by a review of clinical records.

[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 31 Ok Reg 2034, eff 10-1-14]