All psychological services will be reflected by documentation in the patient records.

1. (1) All assessment, testing, and treatment services/units billed must include the following:

   1. (A) date;
   2. (B) start and stop time for each session/unit billed;
   3. (C) signature of the provider;
   4. (D) credentials of provider;
   5. (E) specific problem(s), goals and/or objectives addressed;
   6. (F) methods used to address problem(s), goals and objectives;
   7. (G) progress made toward goals and objectives;
   8. (H) patient response to the session or intervention; and
   9. (I) any new problem(s), goals and/or objectives identified during the session.
2. (2) For each Group psychotherapy session, a separate list of participants must be maintained.
3. (3) Psychological testing will be documented for each date of service performed which should include at a minimum, the objectives for testing, the tests administered, the results/conclusions and interpretation of the tests, and recommendations for treatment and/or care based on testing results and analysis.

Added at 18 Ok Reg 2959, eff 5-17-01 (emergency)

Added at 19 Ok Reg 1067, eff 5-13-02

Amended at 23 Ok Reg 2554, eff 6-25-06

Amended at 26 Ok Reg 2111, eff 6-25-09