Wisconsin Administrative Code › Department of Health Services › DHS 30-100 - Community Services › Chapter DHS 40 - Mental Health Day Treatment For Youth › Section DHS 40.15 - Client records

Current through June 24, 2024
(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.