SECTION 450:60-7-5. Clinical record content, intake assessment

(a)   All facilities shall assess each individual to determine appropriateness of admission.

(b)   The CEDT shall document the first contact per episode between the potential consumer and the CEDT to determine appropriateness of admission.

(c)   Consumer intake assessment information shall contain but not be limited to the following:

(1)   Date, to include month, day and year of the interview or intake, including re-admissions for CEDT services;

(2)   Source of information;

(3)   Consumer's first name, middle initial, and last name;

(4)   Gender;

(5)   Birth date;

(6)   Home address;

(7)   Telephone number;

(8)   Referral source;

(9)   Reason for referral;

(10)   Significant other to be notified in case of emergency;

(11)   Presenting problem and disposition;

(12)   Health and drug history information, with drug history information to include the following for both current and past medications:

(A)   Name of medication,

(B)   Strength and dosage of medication,

(C)   Length of time consumer was on the medication, if known,

(D)   Benefit(s) of medication, and

(E)   Side effects;

(13)   Psychosocial information, which shall include:

(A)   Personal history, including:

(i)   Family - social,

(ii)   Educational,

(iii)   Cultural - moral beliefs,

(iv)   Occupational - military,

(v)   Sexual,

(vi)   Marital,

(vii)   Domestic violence or sexual assault,

(viii)   Recreation and leisure,

(ix)   Financial,

(x)   Clinical treatment history including medical and psychiatric treatment,

(xi)   Legal or criminal record,

(xii)   Substance use, abuse, and dependence.

(B)   Present life situation;

(C)   Interviewer's interpretation of findings;

(D)   What consumer wants in terms of service;

(E)   Disposition;

(F)   Mental status information, including questions regarding:

(i)   Physical presentation, such as general appearance, motor activity, attention and alertness, etc.,

(ii)   Affective process, such as mood, affect, manner and attitude, etc., and

(iii)   Cognitive process, such as intellectual ability, social-adaptive behavior, thought processes, thought content, and memory, etc.;

(G)   Level of Functioning;

(H)   Signature of interviewer and professional credentials, if any.

(14)   Additional information as required by the facility.

(d)   The CEDT shall have policy and procedures that dictate timeframes by when intake assessment must be completed for each program service to which a client is admitted.

(e)   An intake assessment update, to include date, identifying information, source of information, present problems, present life situation, current level of functioning, and what the consumer wants in terms of service, is acceptable only on re-admissions within one (1) year of previous admission.

[Source: Added at 23 Ok Reg 1617, eff 4-25-06 (emergency); Added at 24 Ok Reg 1428, eff 7-1-07]