SECTION 75:25-3-4.1. Record Content

(a)   Client records shall contain, at a minimum, the following information:

(1)   Intake information:

(A)   assessment information;

(B)   date of intake if different than date of assessment;

(C)   emergency contact information (not the victim or abused partner);and

(D)   current employer, if applicable.

(2)   Service notes for each batterer shall be completed by staff or volunteer after individual contact and every weekly session which shall minimally include:

(A)   The time, date, location and description of services provided;

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

(C)   A service note shall be completed by the staff or volunteer providing the service for each weekly group contact, and shall include:

(i)   personal responsibility and accountability;

(ii)   level of participation in services;

(iii)   change(s) in family, social, personal, legal or work environment(s);

(iv)   inference of use or increased use of drugs/alcohol;

(v)   whether or not facilitator observed sufficient indications of risk requiring notification of victim or others, and

(vi)   Referrals for supplemental services.

(D)   Staff or volunteer service notes shall document the ongoing provision of educational components addressing the risk of battering and other violence as set forth in 75:25-3-1(b).

(3)   An individualized written contract shall be completed upon acceptance into the program prior to the first (1st) group session; signed by the batterer; and shall include, but not be limited to:

(A)   Notice that the batterer is joining an educational program, not a therapeutic program, and will not have the same level of confidentiality afforded by mental health services. The program will not assure confidentiality with respect to:

(i)   Judge, District Attorney or referring agency

(ii)   current partner

(iii)   past or current victim(s)

(iv)   parent(s) or guardians of any of thebatterers children

(v)   probation and parole

(vi)   law enforcement

(vii)   individuals toward whom there is a risk of imminent harm by the batterer

(viii)   Coordinated Community Response Team

(ix)   the domestic violence victim services program serving the area where the batterer lives or where the current or ex-partner lives, where guardians of the batterers' children live or with the domestic violence program where the batterer is currently residing

(x)   Guardian Ad Litems

(xi)   the program will promise confidentiality with respect to: the general public, news media and anyone else not covered in the expectations set forth above

(B)   Attendance policy, including the length of intervention, minimum number of sessions required and the maximum length of time for completion of the required sessions.

(C)   The criteria for suspension and termination.

(D)   The program's rules.

(E)   A written notice in bold type which specifies "Please be advised any reasonable knowledge or suspicion of illegal activities or bodily harm, or a threat of such, to the victim, her or his property, or to third persons, or any attempt, threat or gesture to commit suicide, or any belief that child abuse or neglect is present or has occurred, will be reported to the appropriate person(s) or authorities."

(F)   A list of provider program expectations, such as participation, and that the batterer will be held accountable for all abusive and violent behavior or threats of harm or expressions of intent to do harm. This includes harm to current or past victims or partners. Such acts include but are not limited to child abduction, court actions for divorce or custody, underhanded economic maneuvers, substance use, and intentionally exposing the victim(s) or partner(s) to risk of sexually transmitted diseases.

(4)   Reports. In the case of court-ordered or otherwise referred batterers, a written report to the court or referring agency shall be submitted within seven (7) business days of the following events:

(A)   Acceptance into the program including, but not limited to, a summary of the results of the initial assessment. Rejection or denied admission to the program including, but not limited to, a summary of the results of the initial assessment, reason for rejection or denial, and any alternative service recommendations; and

(B)   Reasonable knowledge or suspicion of illegal activities or bodily harm, abuse or a threat of such, to the victim, children or to third persons; and

(C)   Exit from the program including, but not limited to, the service termination report which shall summarize the type of termination and reason for termination.

(i)   Rejection. Reasons for rejection shall be documented and include, but are not limited to: psychiatric history, including active or recent mental health related problems; criminal record of violent crimes; chemical dependency requiring completion of an impatient or residential treatment program; inability to function in a group due to limited mental cognitive abilities; or needs that do not match services provided by this program;

(ii)   Involuntary termination. Reasons for involuntary termination shall be documented and include, but are not limited to: recurrence of violence; arrest; absences from program sessions and activities; failure to actively participate in group sessions attended; attending a group session when under the influence of alcohol or drugs; violation of any rules of the program or violation of the BIP contract;

(iii)   Completion. Upon completion of the program, an exit interview and service termination report shall be completed and documented in the client record. It shall be documented that the client participated in planning for the client's exit from the program. The client and staff shall sign and date acknowledgment of this service or an explanation shall be documented if staff is unable to obtain the client's signature. The service termination report shall include a disclosure stating that completion of the batterer's intervention program does not indicate that the client will not re-offend; it is a report that the person has completed the necessary requirements of the certified program without any other known or reported re-offending during the time of enrollment in the program.

(5)   All reports shall include specific lethality risk indicators that the court may want to seriously consider and any concerns for the safety of victims, children and/or others.

(6)   All reports shall include any perceived areas of concern which may include, but are not limited to, substance abuse or mental health issues.

(7)   Where required information is not obtained, efforts to comply with the requirements of this subsection shall be documented in the client record.

(8)   Compliance with this 75:25-3-4 shall be determined by a review of client records for content, review of program policy and procedures, or other supporting program documentation.

[Source: Added at 35 Ok Reg 871, eff 9-14-18]