SECTION 75:30-5-3. 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, including substance abuse;

(D)   Emergency contact information, if applicable;

(E)   History/nature of abuse including an evidence-based dangerousness assessment, if applicable and safety planning, screening for medical, mental health and substance abuse, status including eligibility for other services and HHS or ORR certification; and

(F)   Perpetrator(s) information, if known.

(2)   Service notes, which shall minimally include:

(A)   The date, location, start time, duration and description of services provided delineated by time spent and service code, if applicable, or documentation of referral to other services or case management; and

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

(3)   Service plan focusing on victim safety and well-being which shall minimally include:

(A)   Goals and objectives of the client, which shall be developed and agreed upon between the client and staff or volunteer, and

(B)   Service plans and their updates shall be signed and dated by the client and staff.

(4)   Exit information, which shall minimally include:

(A)   Documentation that the client participated in planning for his or her 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 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 75:30-5-3 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: Added at 28 Ok Reg 1931, eff 7-11-11; Amended at 31 Ok Reg 820, eff 9-12-14; Amended at 33 Ok Reg 1226, eff 9-11-16; Amended at 35 Ok Reg 882, eff 9-14-18]