 |
Oklahoma Administrative Code (Last Updated: March 11, 2021) |
 |
TITLE 450. Department of Mental Health and Substance Abuse Services |
|
Chapter 60. Standards and Criteria for Certified Eating Disorder Treatment Programs |
|
Subchapter 7. Facility Clinical Records |
SECTION 450:60-7-8. Progress notes
Latest version.
- (a) Progress notes shall chronologically describe the consumer's progress in treatment and document the consumer's response to services related to the treatment.(b) Progress notes shall address the following:(1) Person(s) to whom services were rendered;(2) Activities and services provided as they relate to the goals and objective of the service plan, including ongoing reference to the service plan;(3) Documentation of the progress or lack of progress made in treatment as it relates to the service plan;(4) Documentation of the implementation of the individualized service plan, including consumer activities and services and all treatment rendered;(5) The consumer's current status;(6) Documentation of the consumer's response to treatment services, changes in behavior and mood, and outcome of treatment or services;(7) Plans for continuing therapy or for discharge, whichever is appropriate; and(8) Family's response to services provided when applicable.(c) Progress notes shall be documented according to the following time frames:(1) Outpatient staff must document each visit or transaction including missed appointments;(2) Residential nursing staff must document each shift; and(3) Residential physicians, psychotherapists, and dietitians must document each unit of service provided.