All services must be reflected by documentation in the patient records. All assessment and treatment services must include the following:

1. (1) date;
2. (2) start and stop time for each timed treatment session;
3. (3) signature of the service provider;
4. (4) credentials of service provider;
5. (5) documentation of the referral source;
6. (6) problems(s), goals and/or objectives identified on the treatment plan;
7. (7) methods used to address the problem(s), goals and objectives;
8. (8) progress made toward goals and objectives;
9. (9) patient response to the session or intervention; and
10. (10) any new problem(s), goals and/or objectives identified during the session.

Added at 25 Ok Reg 423, eff 11-1-07 (emergency)

Added at 25 Ok Reg 1161, eff 5-25-08