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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 24. Standards and Criteria for Comprehensive Community Addiction Recovery Centers |
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Subchapter 7. Facility Clinical Records |
SECTION 450:24-7-9. Progress Notes
Latest version.
- (a) Progress notes shall chronologically describe the services provided, the consumer's response to the services provided and the consumer's progress in treatment.(b) Progress notes shall address the following:(1) date;(2) consumer's name;(3) Start and stop time for each timed treatment session or service;(4) type of service provided; and(5) signature of the service provider with their credential(s).(c) Outpatient staff must document each visit or transaction, except for assessment completion or service plan development, including missed appointments.(d) Compliance with 450:24-7-9 shall be determined by a review of clinical records and policies and procedures.