Section 40.13. Client records.

 

(1)   Individual treatment record. A program shall maintain a treatment record for each client. The treatment record shall include accurate documentation of all staff services provided to the client, all activities in which the client participates and all other interventions with or on behalf of the client and his or her family, and the improvement, regression or other changes exhibited by the client and his or her family while in the program. A treatment record shall include:

(a) Initial referral materials;

(b) Notes and reports made while screening the client for admission;

(c) A copy of the letter under s. DHS 40.08 (5) accepting or rejecting the referral;

(d) The report under s. DHS 40.09 (3) of the multidisciplinary assessment of the client and his or her family;

(e) Reports and other evaluations of the client and his or her family which were used in developing the initial assessment, and any necessary releases or authorizations for acquiring and using these reports and evaluations;

(f) Results of additional evaluations and other assessments performed while the client is enrolled in the program;

(g) The individual treatment plan for the client and his or her family and the signed approval of the treatment plan;

(h) Written documentation of services provided to the client and client progress as required under s. DHS 40.10 (5) (c) ;

(i) Written summaries of the reviews of the treatment plan pursuant to s. DHS 40.10 (5) (b) 4. ;

(j) Documentation of discharge planning and planned aftercare services;

(k) Medication records, if program staff dispense medications, including documentation of both over-the-counter and prescription medications dispensed to clients. Medication records shall contain documentation of ongoing monitoring of the administration of medications and detection of adverse drug reactions. All medication orders in the client treatment record shall specify the name, type and purpose of the medication, and the dose, route of administration, frequency of administration, person administering and name of the physician who prescribed the medication;

(L) Records of referrals of the client and his or her family to outside resources;

(m) Written consent or the court order or county department authorization under s. DHS 40.08 (8) to admission, and any consent for disclosure or authorization for release of information required under s. 51.30 , Stats., and ch. DHS 92 ;

(n) Records of any grievances lodged by the client, his or her family or other persons relating to the client's treatment, and documentation of the program's response to each grievance; and

(o) Treatment plan case conference and consultation notes.

(2)   Education records. Education records of a client shall be kept separate from the client's treatment record, and shall comply with federal and state statutes and regulations relating to educational records.

(3)   Maintenance and security. The program director is responsible for the maintenance and security of client treatment records.

(4)   Location and format. Client treatment records shall be kept in a central place, be managed in accordance with standard professional practices for the maintenance of patient mental health records, and arranged in a format which provides for consistent recordkeeping within the program and which facilitates accurate and efficient record retrieval.

(5)   Confidentiality and retention of records. Client treatment records shall be kept confidential and safeguarded and retained as required under s. 51.30 , Stats., and ch. DHS 92 .

(6)   Disposition upon program closing. A program shall establish a plan for maintenance and disposition of records in the event the program closes.

History: Cr. Register, August, 1996, No. 488 , eff. 9-1-96; corrections in (1) (m) and (5) made under s. 13.93 (2m) (b) 7. Stats., Register January 2004 No. 577 ; corrections in (1) (m) and (5) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635 .

Note

Federal and state statutes and regulations relating to educational records are 20 USC 1232g and 34 CFR Pt. 99, and s. 118.125 , Stats. Microsoft Windows NT 6.1.7601 Service Pack 1