Oklahoma Administrative Code
Title 450 - Department of Mental Health and Substance Abuse Services
Chapter 55 - Standards and Criteria for Programs of Assertive Community Treatment
Subchapter 5 - PACT Clinical Documentation
Section 450:55-5-1 - Clinical record keeping system

(a) Each PACT shall maintain an organized clinical record keeping system to collect and document information appropriate to the treatment processes. This system shall be organized with easily retrievable, usable clinical records stored under confidential conditions and with planned retention and disposition. For each consumer, the PACT team shall maintain a treatment record that is confidential, complete, accurate, and contains up-to-date information relevant to the consumer's care and treatment.

(b) The team leader and the program assistant shall be responsible for the maintenance and security of the consumer clinical records.

(c) The consumer's clinical records shall be located at the PACT team's main office and, for confidentiality and security, are to be kept in a locked file.

(d) Compliance with 450:55-5-1 shall be determined by on-site observation, a review of PACT policy, procedures or operational methods, clinical records and other PACT provided documentation.