Section 63.15. Client records.

 

(1)  A CSP shall maintain a treatment record for each client. The record shall include information that is sufficiently detailed to enable a person not familiar with the CSP to identify the types of services the client has received.

(2)  The CSP director is responsible for the maintenance and security of client treatment records.

(3)  Client treatment records shall be maintained in a central location.

(4)  Client treatment records shall be kept confidential and safeguarded as required under s. 51.30 , Stats., and ch. DHS 92 .

(5)  The treatment recordkeeping format shall provide for consistency within the CSP and shall facilitate information retrieval. Treatment records shall include:

(a) Results of all examinations, tests and other assessment information;

(b) Reports from referring sources;

(c) Treatment and service plans, except for records of hospital emergency services;

(d) Medication records, which shall document ongoing monitoring of administration of medications and the detection of adverse drug reactions. All medication orders in the client treatment record shall specify the name of the medication, dose, route of administration, frequency of administration, person administering and name of the physician who prescribed the medication;

(e) Records of referrals of the client to outside resources;

(f) Reports from outside resources;

(g) Multidisciplinary case conference and consultation notes;

(h) Consent for disclosure of information release forms;

(i) Progress notes which shall document the location where the service was provided; and

(j) Discharge documentation.

(6)  There shall be a policy governing the disposal of client records.

(7)  There shall be a policy concerning the disposition of client records in the event of the CSP closing.

History: Cr. Register, April, 1989, No. 400 , eff. 5-1-89; correction in (4) made under s. 13.93 (2m) (b) 7., Stats., Register December 2004 No. 588 ; correction in (4) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635 .