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OHCA Policies and Rules

317:30-3-65.6. Documentation of Services

[Revised 10-01-18]

Records for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screens must contain adequate documentation of services rendered. Such documentation must include the physicians' signature or identifiable initials for every prescription or treatment. Documentation of records may be completed manually or electronically in accordance with guidelines found at OAC 317:30-3-15. Each required element of the age specific screening must be documented with a description of any noted problem, anomaly or concern. In addition, a plan for following necessary diagnostic evaluations, procedures and treatments, must be documented.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.