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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 60. Standards and Criteria for Certified Eating Disorder Treatment Programs |
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Subchapter 7. Facility Clinical Records |
SECTION 450:60-7-10. Discharge summary
Latest version.
- (a) A discharge summary shall document the consumer's progress made in treatment; response to services rendered; and recommendation for any referrals, if deemed necessary.(b) A discharge summary shall be entered in each consumer's record within fifteen (15) days of release, discharge, or transfer from residential treatment or upon discharge from facility services.(c) The discharge summary shall minimally include, but is not limited to:(1) Presenting problem at intake;(2) Medication summary when applicable;(3) Treatment provided and treatment outcome and results;(4) Psychiatric and physical diagnosis or the final assessment;(5) Discharge plan: Written recommendations, specific referrals for implementing aftercare services, including medications. Aftercare plans shall be developed with the knowledge and cooperation of the consumer, when possible;(6) In the event of death of a consumer: A summary statement including this information shall be documented in the record; and(7) Signature of staff member, professional credentials, if any, and date.