Section DHS 40.15 - Client records(1) LOCATION AND FORMAT. Client records shall be managed in accordance with standard professional practices and any applicable legal requirements for the maintenance of client mental health records, and arranged in a format which provides for consistent recordkeeping within the program and which facilitates accurate and efficient record retrieval.(2) ELEMENTS. All entries in each client file shall be factual, accurate, legible, permanently recorded, dated, and authenticated with the signature and license or title of the staff member making the entry. An electronic representation of the staff member's signature shall be used only by the staff member who makes the entry. The program shall possess a statement signed by the staff member, which certifies that only that staff member shall use the electronic representation via use of a personal password.(3) CONFIDENTIALITY AND RETENTION OF RECORDS. Client records shall be kept confidential and safeguarded and retained as required under 42 CFR part 2, 45 CFR parts 160, 162, 164, and s. 51.30, Stats., ch. DHS 92, and any other applicable law.(4) CONSENT. The treatment record shall document that the youth or legal representative were informed of the nature and policies of the program in their primary language and that the youth or legal representative understood and agreed to participation in the program.(5) CLIENT TREATMENT RECORD. A treatment file or electronic record shall include all of the following: (a) Initial referral materials.(b) Notes and reports made while screening the youth for admission.(c) A copy of the screening summary under s. DHS 40.11(3).(d) The safety plan under s. DHS 40.12(4).(e) The written, signed assessment under s. DHS 40.13(2).(f) Reports and other evaluations of the youth which were used in developing the assessment, and any necessary releases or authorizations for acquiring and using these reports and evaluations.(g) Results of additional evaluations and other assessments performed while the youth is enrolled in the program.(h) The initial, signed individual treatment plan.(i) Descriptions of significant events that are related to the youth's treatment plan and contribute to an overall understanding of the youth's ongoing level and quality of functioning.(j) Any recommended changes or improvements of the treatment plan resulting from clinical collaboration or clinical oversight.(k) Written documentation of the services that have been provided to the youth or their legal representative as required under s. DHS 40.07(4).(l) Written summaries of the reviews of the treatment plan pursuant to s. DHS 40.14(2) (c).(m) Documentation of transition services and discharge planning, including involuntary discharge.(n) Informed consent for treatment medication administration and medication records, if staff members dispense medications, including documentation of both over-the-counter and prescription medications dispensed to youth. Medication records shall contain documentation of ongoing monitoring of the administration of medications and detection of adverse drug reactions. All medication orders in the youth treatment record shall specify the name, type and purpose of the medication, and the dose, route of administration, frequency of administration, staff member administering, and name of the prescriber who prescribed the medication.(o) Records of referrals of the youth to outside resources.(p) Written consent, the court order, or county department authorization under s. DHS 40.12(2) (a) to admission, and any consent for disclosure or authorization for release of information required under s. 51.30, Stats., and ch. DHS 92.(q) Treatment plan case reviews and consultation notes.(r) Care coordination provided with the youth or legal representative.(s) Any other information that is appropriate for the youth file.(6) ELECTRONIC TREATMENT RECORDS. (a) Programs may maintain treatment records electronically if the program has a written policy describing the records and the authentication and security policy.(b) Electronic transmission of information from treatment records to information systems outside the program shall not occur without voluntary written consent for disclosure from the youth or legal representative per s. 51.30, Stats., or as otherwise provided by law.(7) EDUCATION RECORDS. Education records of a youth shall be kept separate from the youth's treatment record, and shall comply with federal and state statutes and regulations relating to educational records. Note: Federal and state statutes and regulations relating to educational records are found in 20USC 1232g and 34 CFR Pt. 99, and s.118.125, Stats.
(8) MAINTENANCE AND SECURITY. The program director is responsible for the maintenance and security of client treatment records.(9) DISPOSITION UPON PROGRAM CLOSING. A program shall establish a written policy for maintenance and disposition of records, in accordance with s. DHS 92.12, in the event the program closes.Wis. Admin. Code Department of Health Services § DHS 40.15
Cr. Register, August, 1996, No. 488, eff. 9-1-96; corrections made under s. 13.93(2m) (b) 7, Stats., Register January 2004 No. 577; correction in (2) made under s. 13.92(4) (b) 7, Stats., Register November 2008 No. 635; correction in (1) made under s. 13.92(4) (b) 7, Stats., Register February 2012 No. 674.Adopted by, CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20; correction in (3), (5) (k) made under s. 35.17, Stats., Register June 2020 No. 774, eff. 7/1/2020