Oklahoma Administrative Code
Title 450 - Department of Mental Health and Substance Abuse Services
Chapter 17 - Standards and Criteria for Community Mental Health Centers
Subchapter 7 - Facility Clinical Records
Section 450:17-7-5 - Clinical record content, screening and assessment

(a) All facilities shall complete a face-to face screening with each individual to determine appropriateness of admission.

(b) The CMHC shall document the face-to-face screening between the potential consumer and the CMHC including how the consumer was assisted to identify goals, how the consumer received integrated screening to identify both immediate and ongoing needs and how the consumer was assisted to determine appropriateness of admission, and/or to access other appropriate services.

(c) Upon determination of appropriate admission, consumer demographic information shall be collected.

(d) All programs shall complete a psychosocial assessment which gathers sufficient information to assist the consumer in developing an individualized service plan.

(e) The CMHC shall have policy and procedures that stipulate content required for items (c) and (d).

(f) An assessment update, to include date, identifying information, source of information, present needs, present life situation, current level of functioning, and what consumer wants in terms of service, is acceptable only on re-admissions within one (1) year of previous admission.

(g) Compliance with 450:450:17-7-5 shall be determined by a review of the following: psychosocial assessment instruments; consumer records; case management assessments; interviews with staff and consumers; policies and procedures and other facility documentation.