SECTION 75:15-5-3. Record content - general

(a)   Client records for both residential and non-residential clients shall contain, at a minimum, the following information:

(1)   Intake and screening information:

(A)   Client's name;

(B)   Date of initial contact/intake;

(C)   Pertinent medical information;

(D)   Emergency contact information;

(E)   History/nature of abuse including an evidence-based, dangerousness assessment and screening for stalking and trauma including a description of the event that precipitated the request for services and safety planning;

(F)   Screening for strangulation and head trauma, if applicable, information shall be given to client; and

(G)   Perpetrator information if known.

(2)   Service notes, which shall minimally include:

(A)   The date, location, start time, duration and description of service provided delineated by time spent and service code; and

(B)   The signature of staff or volunteer providing the services.

(3)   Service plan shall focus on victim safety and well-being which shall minimally include goals and objectives of the client, which shall be agreed upon between the client and staff or volunteer.

(4)   Exit information, which shall minimally include:

(A)   Documentation that the client participated in planning for the client's exit from the program;

(B)   The reasons for the client's exit or departure; and

(C)   Client and staff or volunteer dated signatures or an explanation if staff or the volunteer were unable to obtain the client's signature.

(b)   Each client record entry shall be legible, dated and signed by the staff member or volunteer making the entry.

(c)   Compliance with 75:15-5-3 shall be determined by a review of program policies and procedures, review of the client records for content and/or other supporting program documentation.

[Source: Transferred from 450:19-5-3 by SB 236 (2005), eff 7-1-05 (Editor’s Notice published at 22 Ok Reg 2667); Amended at 23 Ok Reg 339, eff 11-8-05 (emergency); Amended at 23 Ok Reg 2200, eff 7-1-06; Amended at 24 Ok Reg 2508, eff 7-15-07; Amended at 25 Ok Reg 1838, eff 7-1-08; Amended at 26 Ok Reg 2426, eff 7-11-09; Amended at 27 Ok Reg 1709, eff 7-1-10; Amended at 28 Ok Reg 1906, eff 7-11-11; Amended at 29 Ok Reg 1759, eff 8-11-12; Amended at 30 Ok Reg 1915, eff 7-25-13; Amended at 33 Ok Reg 1195, eff 9-11-16; Amended at 35 Ok Reg 863, eff 9-14-18]