Library: Policy

317:30-5-560.2. Record documentation

Revised 9-12-22

(a) The treatment plan must be updated and signed by the attending physician [medical doctor (MD), or doctor of osteopathy, (DO)], a physician assistant (PA), or advanced practice registered nurse (APRN) at least annually.

(b) Copies of the attending physician's orders and, at a minimum, the last thirty (30) days of medical records for the actual care provided must be maintained and include the following:

(1) The beginning and ending time of the care and must be signed by the person providing care;

(2) The nurse's credentials;

(3) All provisions of the treatment plan, such as vital signs, medication administration, glucose/neuro checks, vital signs, respiratory assessments, and all applicable treatments must be documented; and

(4) Meet the record retention requirements set forth in Oklahoma Administrative Code (OAC) 317:30-3-15.