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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 55. Standards and Criteria for Programs of Assertive Community Treatment |
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Subchapter 5. Pact Clinical Documentation |
SECTION 450:55-5-4. Initial assessment and treatment plan
Latest version.
- (a) The initial assessment data shall be collected, to the extent available, and evaluated by PACT team leader or appropriate staff designated by the team leader. Such assessments shall be based upon all available information, which may include self-reports, reports of family members and other significant parties, and written summaries from other agencies, including police, courts, and outpatient and inpatient facilities, where applicable, culminating in a comprehensive initial assessment. Consumer assessment information for admitted consumers shall be completed within five (5) days of admission to the PACT.(b) The initial assessment shall contain, but not be limited to, the following identification data:(1) Consumer's name;(2) Date of admission to PACT;(3) Social Security number;(4) Presenting problem/client self-assessment of problem;(5) Reason for treatment;(6) Availability of social supports and resources;(7) History of psychiatric illness and previous services;(8) Current functioning;(9) Admitting diagnosis;(10) Justification for Admission; and,(11) Primary case manager (Certified Behavioral health Case Manager) and individual treatment team (ITT).(c) The initial treatment plan is completed within five (5) days of admission and guides team services until the comprehensive assessment and comprehensive treatment plan is completed. Interventions from the initial treatment plan should be reported on the consumer weekly schedule card. The initial treatment plan shall contain, but not be limited to, the following identification data:(1) Consumer's name;(2) Date;(3) Short term goals;(4) Problems to be addressed;(5) Objectives;(6) Consumer or guardian participation;(7) Consumer's signatures; and,(8) Team leader's signature.(d) Compliance with 450:55-5-4 shall be determined by a review of the following: intake assessment instruments and other intake documents of the PACT program, clinical records and other agency documentation of admission materials or requirements.