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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 27. Standards and Criteria for Mental Illness Service Programs |
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Subchapter 7. Clinical Services |
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Part 5. CLINICAL DOCUMENTATION |
SECTION 450:27-7-41. Clinical record content, screening, intake and assessment, documentation
Latest version.
- (a) The facility shall complete a face-to face screening with each individual to determine appropriateness of admission in accordance with 450:27-7-2. Screening services.(b) The facility shall document the face-to-face screening conducted how the consumer was assisted to identify goals, how the consumer received integrated screening to identify both immediate and ongoing needs and how the consumer was assisted to determine appropriateness of admission, and/or to access other appropriate services.(c) Each consumer admitted for treatment for co-occurring services shall be assessed by a qualified professional demonstrating competency in the use of ASAM criteria, according to ASAM criteria, which includes a list of symptoms for all six dimensions and each level of care, to determine a clinically appropriate placement in the least restrictive level of care. Facilities must ensure that a consumer's refusal of a particular service does not preclude the consumer from accessing other needed co-occurring treatment services. Should the service provider determine the consumer's needs cannot be met within the facility, clinical assessments and referrals for the consumer shall be documented.(d) Upon determination of appropriate admission, consumer demographic information shall be collected, as defined by facility policies and procedures.(e) For persons admitted to service, the facility shall complete a psychological-social assessment which gathers sufficient information to assist the consumer develop an individualized service plan.(f) An intake assessment update, to include date, identifying information, source of information, present needs, present life situation, current level of functioning, and what consumer wants in terms of service, is acceptable as meeting requirements of 450:27-7-41 only on re-admissions within one (1) year of previous admission at the facility.(g) Compliance with 450:450:27-7-41 shall be determined by a review of the following: psychological-social assessment instruments; consumer records; case management assessments; interviews with staff and consumers; policies and procedures and other facility documentation.