Oklahoma Administrative Code
Title 317 - Oklahoma Health Care Authority
Chapter 30 - Medical Providers-Fee for Service
Subchapter 5 - Individual Providers and Specialties
Part 62 - PRIVATE DUTY NURSING
Section 317:30-5-560.2 - Record documentation
Universal Citation: OK Admin Code 317:30-5-560.2
Current through Vol. 42, No. 1, September 16, 2024
(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.
Added at 23 Ok Reg 33, eff 8-1-05 (emergency); Added at 23 Ok Reg 1364, eff 5-25-06; Amended at 24 Ok Reg 333, eff 12-1-06 (emergency); Amended at 24 Ok Reg 930, eff 5-11-07
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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