Section DHS 36.18 - Consumer service records(1) Each consumer service record shall be maintained pursuant to the confidentiality requirements under HIPAA, s. 51.30, Stats., ch. DHS 92 and, if applicable, 42 CFR Part 2. Electronic records and electronic signatures shall meet the HIPAA requirements in 45 CFR 164, Subpart C.(2) The CCS shall maintain in a central location a service record for each consumer. Each record shall include sufficient information to demonstrate that the CCS has an accurate understanding of the consumer, the consumer's needs, desired outcomes and progress toward goals. Entries shall be legible, dated and signed.(3) Each consumer record shall be organized in a consistent format and include a legend to explain any symbol or abbreviation used. All of the following information shall be included in the consumer's record:(a) Results of the assessment completed under s. DHS 36.16, including the assessment summary.(b) Initial and updated service plans, including attendance rosters from service planning sessions.(c) Authorization of services statements. (d) Any request by the consumer for a change in services or service provider and the response by the CCS to such a request.(e) Service delivery information, including all of the following: 1. Service facilitation notes and progress notes.2. Records of referrals of the consumer to outside resources.3. Descriptions of significant events that are related to the consumer's service plan and contribute to an overall understanding of the consumer's ongoing level and quality of functioning.4. Evidence of the consumer's progress, including response to services, changes in condition and changes in services provided.5. Observation of changes in activity level or in physical, cognitive or emotional status and details of any related referrals.6. Case conference and consultation notes.7. Service provider notes in accordance with standard professional documentation practices.8. Reports of treatment, or other activities from outside resources that may be influential in the CCS's service planning.(f) A list of current prescription medication and regularly taken over the counter medications. Documentation of each prescribed medication shall include all of the following: 1. Name of the medication and dosage.2. Route of administration.4. Duration, including the date the medication is to be stopped.6. Name of the prescriber. The signature of prescriber is also required if the CCS prescribes medication as a service.7. Activities related to the monitoring of medication including monitoring for desired responses and possible adverse drug reactions, as well as an assessment of the consumer's ability to self-administer medication.7m. Medications may be administered only by a physician, nurse, a practitioner, a person who has completed training in a drug administration course approved by the department, or by the consumer.8. If a CCS staff member administers medications, each medication administered shall be documented on the consumer's individual medication administration record (MAR) including, the time the medication was administered and by whom and observation of adverse drug reactions, including a description of the adverse drug reaction, the time of the observation and the date and time the prescriber of the medication was notified. If a medication was missed or refused by the consumer, the record shall explicitly state the time that it was scheduled and the reason it was missed or refused.(g) Signed consent forms for disclosure of information and for medication administration and treatment.(h) Legal documents addressing commitment, guardianship, and advance directives.(i) Discharge summary and any related information.(j) Any other information that is appropriate for the consumer service record.Wis. Admin. Code Department of Health Services DHS 36.18
CR 04-025: cr. Register October 2004 No. 586, eff. 11-1-04; correction in (1) made under s. 13.92(4) (b) 7, Stats., Register November 2008 No. 635.