SECTION 450:27-7-44. Progress notes

(a)   Progress notes shall chronologically describe the services provided, the consumer's response to the services provided, and the consumer's progress in treatment and include the following:

(1)   Date;

(2)   Name of consumer(s) to whom services were rendered;

(3)   Start and stop time for each timed treatment session or service;

(4)   Original signature of the therapist/service provider; in circumstances where it is necessary to fax a service plan to someone for review and then have them fax back their signature, this is acceptable; however, the provider must obtain the original signature for the clinical file within 30 days and no stamped or photocopied signatures are allowed. Electronic signatures are acceptable;

(5)   Credentials of therapist/service provider;

(6)   Specific service plan need(s), goals and/or objectives addressed;

(7)   Services provided to address need(s), goals and/or objectives;

(8)   Progress or barriers to progress made in treatment as it relates to the goals and/or objectives;

(9)   Consumer (and family, when applicable) response to the session or intervention;

(10)   Any new need(s), goals and/or objectives identified during the session or service.

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

(1)   Outpatient staff must document each visit or transaction, except for assessment completion or service plan development, including missed appointments;

(2)   Behavioral health rehabilitation services and day treatment programs for children and adolescents staff must maintain a daily, member sign-in/sign-out record of member attendance, and shall write a progress note daily or a summary progress note weekly.

(c)   Compliance with 450:27-7-44 shall be determined by a review of clinical records and policies and procedures.

[Source: Added at 29 Ok Reg 663, eff 7-1-12; Amended at 36 Ok Reg 1157, eff 11-1-19]