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OHCA Policies and Rules

317:30-5-209. Documentation

[Issued 11-01-07]
All services must be reflected by documentation in the patient records. All assessment and treatment services must include the following:

(1) date;

(2) start and stop time for each timed treatment session;

(3) signature of the service provider;

(4) credentials of service provider;

(5) documentation of the referral source;

(6) problems(s), goals and/or objectives identified on the treatment plan;

(7) methods used to address the problem(s), goals and objectives;

(8) progress made toward goals and objectives;

(9) patient response to the session or intervention; and

(10) any new problem(s), goals and/or objectives identified during the session.

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.