SECTION 450:55-5-9. PACT progress note  

Latest version.
  • (a)   The PACT shall have a policy and procedure mandating the chronological documentation of progress notes. Every contact and service that relates to the consumer's treatment shall be documented.
    (b)   Progress notes shall minimally address the following:
    (1)   Date;
    (2)   Person(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;
    (5)   Credentials of therapist/service provider;
    (6)   Specific treatment plan problems(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)   Location of service;
    (10)   Member (and family, when applicable) response to the session or intervention; (what did the member do in session? What did the provider do in session?);
    (11)   Any new need(s), goals and/or objectives identified during the session or service.
    (c)   Compliance with 450:55-5-9 shall be determined by a review of clinical records.
[Source: Added at 20 Ok Reg 683, eff 2-27-03 (emergency); Added at 21 Ok Reg 1093, eff 7-1-04; Amended at 22 Ok Reg 974, eff 7-1-05; Amended at 24 Ok Reg 1422, eff 7-1-07; Amended at 27 Ok Reg 1015, eff 7-1-10]