Oklahoma Administrative Code (Last Updated: March 11, 2021) |
TITLE 450. Department of Mental Health and Substance Abuse Services |
Chapter 55. Standards and Criteria for Programs of Assertive Community Treatment |
Subchapter 5. Pact Clinical Documentation |
SECTION 450:55-5-2. Basic requirements
Latest version.
- (1) All consumer records shall contain the defined required documentation;(2) Storage, retention and destruction requirements for consumer records;(3) Records maintained in locked equipment under secure measures;(4) Entries in consumer records shall be legible, signed with first name, last name, credentials, and dated by the person making the entry; and(5) The consumer's name typed or written on each sheet of paper or page in the clinical record.(b) Compliance with 450:55-5-2 shall be determined by on-site observation, a review of PACT policy, procedures or operational methods, clinical records, other PACT provided documentation and PI information and reports.