Section DHS 75.20 - Patient case records(1)GENERAL TREATMENT SERVICE case records. (a) With respect to general treatment service case records, the service shall do all of the following: 1. Maintain a case record for each patient.2. The service director or another designated staff member shall be responsible for the maintenance and security of patient case records.3. Safeguard and maintain patient case records in accordance with applicable state and federal security requirements, including all applicable security requirements specified in ch. DHS 92, 42 CFR part 2, 45 CFR parts 164 and 170, and ss. 146.816 and 146.82, Stats.4. Maintain each case record in a format that provides for consistency and facilitates information retrieval.5. Whenever an edit to a signed entry in a patient's case record is made, the service shall document the date of the edit, the name of the individual making the edit, and a brief statement about the reason for the edit, if the prior version of the edited information is not retained by the service.(b) A patient's case record shall include all of the following: 1. The patient's name, physical residence, address, and phone contact information.2. The patient's date of birth, self-identified gender, and self-identified race or ethnic origin.3. Consent for treatment forms signed by the patient or the patient's legal guardian, if applicable, that are maintained in accordance with s. DHS 94.03.4. An acknowledgment by the patient or the patient's legal guardian, if applicable, that the service policies and procedures were explained to the patient or the patient's legal guardian.5. A copy of the signed and dated patient notification that was reviewed with and provided to the patient or the patient's legal guardian, if applicable, which identifies patient rights, and explains provisions for confidentiality and the patient's recourse in the event that the patient's rights have been abused.6. Results of all screening, examinations, tests, and other assessment information.7. A completed copy of the standardized placement criteria and level of care assessment at admission, and subsequent reviews of level of care placement criteria.8. Treatment plans, including all reviews and updates to the treatment plan.9. Records for any medications prescribed or administered by the service, including any medication consent records required by s. DHS 94.09.10. Copies of any incident reports or documentation of medication errors applicable to the patient.11. Records for any medical services provided by the service.12. Reports from referring sources, as applicable.13. Records of any referrals by the service, including documentation that referral follow-up activities occurred.14. Correspondence relevant to the patient's care and treatment, including dated summaries of relevant telephone or electronic contacts and letters.15. Consents authorizing disclosure of specific information about the patient.16. Progress notes that include documentation of all services provided.17. Clinical consultation and staffing notes, as applicable.18. Any safety plans developed during the patient's treatment.19. Documentation of each transfer from one level of care to another. Documentation shall identify the applicable criteria from ASAM or other department-approved placement criteria, and shall include the dates the transfer was recommended and initiated.20. Discharge documentation.(c) For patients that discharge from a service and are subsequently re-admitted, a new case record shall be established for each episode of care.(d) A patient's case record shall be maintained in accordance with ch. DHS 92.(e) If the service discontinues operations or is taken over by another service, records containing patient identifying information shall be turned over to the replacement service, as permitted by applicable state and federal confidentiality requirements.(2)CASE RECORDS FOR PERSONS RECEIVING ONLY SCREENING AND REFERRAL. A treatment service shall have a written policy and procedure regarding case records for individuals that receive only screening, consultation, or referral services. The policy and procedure shall include: (a) Information to be obtained for phone and in-person screening, consultation, or referral.(b) Assurance that screening includes an individual's pregnancy status.(c) Assurance that screening, consultation, and referral procedures address individual risks and needs.Wis. Admin. Code Department of Health Services DHS 75.20
Adopted by, CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22; correction in (1) (a) 3., (b) 3., 9. made under s. 35.17, Stats., Register October 2021 No. 790, eff. 10/1/2022This section is created eff. 10-1-22 by CR 20-047.