In addition to the basic medical record requirements for general medical surgical records, medical records for rehabilitative patients shall include the following:
- (1) The reason for referral or admission to the rehabilitation facility.
- (2) A summary of the patient's clinical condition, functional strengths and limitations, indications and contraindications for specific physical rehabilitation services, and prognosis.
- (3) Initial and comprehensive treatment plans as specified in 310:667-35-3(a)(5). The goals of treatment, any problems that may affect the outcome of rehabilitation, and criteria leading to the discontinuation of services shall be documented.
- (4) Treatment and progress records, with appropriate ongoing assessments as required by the patient's condition. A description of the perception of the patient and family toward, and their involvement in, physical rehabilitation services.
- (5) Assessment of physical rehabilitation achievement and estimates of further rehabilitation potential, entered on a timely basis, which shall be made at least monthly and included in the individualized comprehensive treatment plan.
- (6) A discharge summary that includes the physical rehabilitation achieved, the medications and therapy prescribed at discharge, and recommendations for further rehabilitation.
Added at 12 Ok Reg 1555, eff 4-12-95 (emergency)
Added at 12 Ok Reg 2429, eff 6-26-95