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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 70. Standards and Criteria for Opioid Treatment Programs |
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Subchapter 3. Facility Record System |
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Part 1. RECORD SYSTEM |
SECTION 450:70-3-3. Patient records, basic requirement
Latest version.
- (a) Patient records shall be developed and maintained to ensure that all appropriate individuals have access to relevant clinical and other information regarding the patient. The patient record shall communicate information in a manner that is organized, clear, complete, current and legible. All patient records shall contain the following:(1) Entries in patient records shall be legible, signed with first name or initial, last name, and dated by the person making the entry;(2) The patient shall be identified by name on each sheet in the patient record and on each screen of the electronic record.(3) A signed consent for treatment shall be obtained and placed in the record before any person can be admitted into treatment at an OTP;(4) A signed consent for follow-up shall be obtained and placed in the record before any contact after discharge can be made;(5) An intake and admission assessment;(6) A biopsychsocial assessment;(7) Case management needs assessment;(8) Service planning;(9) Documentation of progress notes;(10) A discharge biopsychsocial assessment;(11) A continuing care plan;(12) Consultation reports;(13) Psychological or psychometric testing;(14) Records and reports from other entities;(15) Medication records;(16) A discharge summary; and(17) Referral and transfer.(b) Compliance with 450:70-3-3 may be determined by:(1) A review of policies and procedures,(2) Treatment records,(3) Performance improvement guidelines,(4) Interviews with staff, and(5) Other facility documentation.