Oklahoma Administrative Code
Title 317 - Oklahoma Health Care Authority
Chapter 30 - Medical Providers-Fee for Service
Subchapter 5 - Individual Providers and Specialties
Part 26 - LICENSED BEHAVIORAL HEALTH PROVIDERS
Section 317:30-5-283 - Documentation of records

Universal Citation: OK Admin Code 317:30-5-283

Current through Vol. 41, No. 20, July 1, 2024

All behavioral health services will be reflected by documentation in the patient records.

(1) All assessment, testing, and treatment services/units billed must include the following:

(A) date;

(B) start and stop time for each session/unit billed;

(C) signature of the provider;

(D) credentials of provider;

(E) specific problem(s), goals, and/or objectives addressed;

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

(G) progress made toward goals and objectives;

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

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

(2) For each Group psychotherapy session, a separate list of participants must be maintained.

(3) Testing will be documented for each date of service performed which should include at a minimum, the objectives for testing, the test administered, the results/conclusions and interpretation of the tests, and recommendations for treatment and/or care based on testing and analysis.

Added at 27 Ok Reg 1676, eff 7-10-10 (emergency); Added at 28 Ok Reg 1483, eff 6-25-11

Disclaimer: These regulations may not be the most recent version. Oklahoma may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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