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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 65. Standards and Criteria for Gambling Treatment Programs |
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Subchapter 3. Gambling Treatment Services and Documentation |
SECTION 450:65-3-10. Consumer records, basic requirement
Latest version.
- (a) CGAT consumer records shall be developed and maintained to ensure that all appropriate individuals have access to relevant clinical and other information regarding the consumer. The consumer record shall communicate information in a manner that is organized, clear, complete, current, and legible. All consumer records shall contain the following:(1) Entries in consumer records shall be legible, signed with first name or initial, last name, and dated by the person making the entry;(2) The consumer shall be identified by name and unique identifier on each sheet in the consumer record, on both sides of each page if both sides are used;(3) A signed consent for treatment shall be obtained before any person can be admitted into treatment at a facility, unless the admission was on an involuntary basis;(4) A signed consent for follow-up shall be obtained before any contact after discharge can be made;(5) An assessment;(6) Documentation of screening to determine the priority of needs to be addressed through case management services;(7) Treatment plans;(8) Progress notes documenting the following:(A) date, start and stop time for each timed treatment session;(B) signature and credentials of the staff person providing the service;(C) specific problem(s), goals and objectives addressed;(D) interventions used to address problem(s), goals and objectives;(E) progress made toward goals and objectives, or lack of;(F) consumer response to the session or intervention;(G) any new problem(s), goals and objectives identified during the session; and(H) consumer's name and unique identifier.(9) A continuing care plan;(10) Consultation reports;(11) Psychological or psychometric testing;(12) Records and reports from other entities; and(13) A discharge summary.(b) In the event the consumer is not admitted and no case record is developed, a policy shall specify how screening and assessment information is maintained and stored.(c) Compliance may be determined by a review of the following:(1) Consumer records;(2) Policy and procedures; and(3) Other facility documentation.