Library: Policy

317:30-5-1046. Documentation of records and records review

Revised 9-1-19

(a) The Organized Health Care Delivery System (OHCDS) and the facilities with whom it contracts must maintain appropriate records system. Current individual plans of care, case files, and progress notes are maintained in the facilities' files during the time the child or youth is receiving services. All services rendered must be reflected by documentation in the case records.

(b) The Oklahoma Health Care Authority (OHCA) and the Centers for Medicare and Medicaid Services (CMS) may evaluate through inspection or other means, the quality, appropriateness and timeliness of services provided by the OHCDS or facilities with whom it contracts.

(c) All Residential Behavioral Management Services (RBMS) in group settings must be reflected by documentation in the patients' records. Individual, group, family, and alcohol and other drug counseling and social and basic living skills development services must include all of the following:

(1) Date;

(2) Start and stop time for each session;

(3) Signature of the therapist/staff providing service;

(4) Credentials of therapist/staff providing service;

(5) Specific problem(s) addressed (problem must be identified on individualized plan of care);

(6) Methods used to address problem(s);

(7) Progress made toward goals;

(8) Patient response to the session or intervention; and

(9) Any new problem(s) identified during the session.