Progress Notes - Oklahoma

Progress Notes is a legal document that was released by the Oklahoma Department of Mental Health and Substance Abuse Services - a government authority operating within Oklahoma.

FAQ

Q: What are progress notes?A: Progress notes are written records of a client's or patient's progress during a specific period of time.

Q: Why are progress notes important?A: Progress notes are important for tracking and documenting a client's or patient's progress, as well as for legal and insurance purposes.

Q: Who writes progress notes?A: Progress notes are typically written by healthcare professionals such as doctors, nurses, therapists, or social workers.

Q: What information is included in progress notes?A: Progress notes can include information on the client's or patient's symptoms, treatment plans, medications, and any changes or improvements observed.

Q: How often are progress notes written?A: The frequency of progress notes can vary depending on the client's or patient's needs, but they are typically written after each session or visit.

Q: Who has access to progress notes?A: Access to progress notes is usually limited to healthcare professionals involved in the client's or patient's care, as well as authorized personnel for legal or insurance purposes.

Q: Can progress notes be used in court?A: Yes, progress notes can be used as evidence in court for legal matters related to a client's or patient's treatment or condition.

Q: Do progress notes need to be kept confidential?A: Yes, progress notes are considered confidential medical records and should be kept secure and only shared with authorized individuals.

Q: Can a client or patient request their own progress notes?A: Yes, clients or patients generally have the right to request and access their own progress notes, although there may be certain restrictions or procedures in place.

Q: What should be done if there is a mistake in a progress note?A: If a mistake is made in a progress note, it should be corrected with a single line strike-through, followed by the correct information and the healthcare professional's initials.