1. (a) The OTP shall ensure that a refusal of a particular service by a person served does not preclude the person served from accessing other needed mental health or substance use disorder treatment services. Should the service provider determine the needs of the person served cannot be met within the facility, clinical documentation of assessments and referrals for the person served shall contain, at a minimum:

   1. (1) Date of initial contact requesting services;
   2. (2) Identification information, including the name, home address and telephone number of the person served;
   3. (3) Referral source;
   4. (4) Mental status examination and results;
   5. (5) History and physical;
   6. (6) Family to be notified in case of emergency;
   7. (7) A continuing care plan;
   8. (8) What agency was contacted; and
   9. (9) Where and why the individual was referred.

2. (b) Compliance with 450:70-3-5.16 may be determined by:

   1. (1) A review of policies and procedures,
   2. (2) Treatment records, and
   3. (3) Other facility documentation.

Added at 30 Ok Reg 1425, eff 7-1-13

Amended at 34 Ok Reg 1830, eff 10-1-17

Amended at 40 Ok Reg 1079, eff 9-15-23