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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 450:55-5-5. Comprehensive assessment
Latest version.
- (a) The consumer's psychiatrist or APN, primary PACT case manager, and individual treatment team members shall prepare the written comprehensive assessment(s) within six (6) weeks of admission.(b) The comprehensive assessment shall be based on information gathered and obtained from the ASI and CAR and include a written narrative report on the ODMHSAS approved comprehensive assessment form. The comprehensive assessment must also include a historical timeline by all team members under the supervision of the team leader.(c) The historical timeline shall contain, but not be limited to psychiatric inpatient/outpatient services history:(1) Timeline dates;(2) Admission/Discharge dates;(3) Institution/provider;(4) Presenting problem/legal status;(5) Diagnosis, symptoms, and significant events;(6) Medications(7) Services received; and(8) Reasons for discharge.(d) Compliance with 450:55-5-5 shall be determined by on-site observation and a review of the clinical records, PICIS information and the PACT policy and procedures.