Okla. Admin. Code § 450:24-7-5
Clinical record content, screening and assessment
Effective Sep 15, 202239 Ok Reg 1998Added at 28 Ok Reg 2025, eff 10-1-11; Amended at 34 Ok Reg 1806, eff 10-1-17; Amended at 35 Ok Reg 1845, eff 10-1-18; Amended at 38 Ok Reg 1343, eff 9-15-21; Amended at 39 Ok Reg 1998, eff 9-15-22Department of Mental Health and Substance Abuse Services
- (a) All facilities shall complete a face-to face screening with each individual to determine appropriateness of admission.
- (b) The CCARC shall document the face-to-face screening between the potential consumer and the CCARC including how the consumer was welcomed and engaged, how the consumer was assisted to identify goals and experience hope, 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) All facilities shall assess each consumer for appropriateness of admission to the treatment program. Facilities must ensure that a consumer's refusal of a particular service does not preclude the consumer from accessing other needed mental health or substance-related or addictive disorder treatment services. Should the service provider determine the consumer's needs cannot be met within the facility, clinical assessments and referrals for the consumer shall be documented.
- (d) Any consumer seeking admission to inpatient or residential services, including medically-supervised withdrawal management and non-medical withdrawal management while under the influence or undergoing withdrawal of alcohol or drugs, shall be assessed prior to admission for medical needs. The written criteria to be used for medical needs assessment of persons under the influence or undergoing withdrawal of alcohol or drugs, and the protocols for determining when physician review of the assessment is needed, shall be approved by the facility's consulting physician.
(e) Compliance with 450:18-7-21 may be determined by a review of the following:
- (1) Policies and procedures;
- (2) Intake protocols;
- (3) assessment instruments;
- (4) Treatment records;
- (5) Interviews with staff and consumers; and
- (6) Other facility documentation.
Added at 28 Ok Reg 2025, eff 10-1-11
Amended at 34 Ok Reg 1806, eff 10-1-17
Amended at 35 Ok Reg 1845, eff 10-1-18
Amended at 38 Ok Reg 1343, eff 9-15-21
Amended at 39 Ok Reg 1998, eff 9-15-22