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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 450:55-5-9. 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.