Wisconsin Administrative Code › Department of Health Services › DHS 30-100 - Community Services › Chapter DHS 36 - Comprehensive Community Services For Persons With Mental Disorders And Substance-Use Disorders › Subchapter V - Consumer Services › Section DHS 36.18 - Consumer service records

Current through June 24, 2024
(1) Each consumer
				  service record shall be maintained pursuant to the confidentiality requirements
				  under HIPAA, s.
				  51.30, Stats., ch. DHS 92
				  and, if applicable, 42 CFR Part 2. Electronic records and electronic signatures
				  shall meet the HIPAA requirements in 45 CFR 164, Subpart C.
(2) The CCS shall maintain in a central
				  location a service record for each consumer. Each record shall include
				  sufficient information to demonstrate that the CCS has an accurate
				  understanding of the consumer, the consumer's needs, desired outcomes and
				  progress toward goals. Entries shall be legible, dated and signed.
(3) Each consumer record shall be organized
				  in a consistent format and include a legend to explain any symbol or
				  abbreviation used. All of the following information shall be included in the
				  consumer's record:
(a) Results of the
				  assessment completed under s.
				  DHS 36.16,
				  including the assessment summary.
(b) Initial and updated service plans,
				  including attendance rosters from service planning sessions.
(c) Authorization of services statements.
(d) Any request by the consumer for
				  a change in services or service provider and the response by the CCS to such a
				  request.
(e) Service delivery
				  information, including all of the following:
1. Service facilitation notes and progress
				  notes.
2. Records of referrals of
				  the consumer to outside resources.
3. Descriptions of significant events that
				  are related to the consumer's service plan and contribute to an overall
				  understanding of the consumer's ongoing level and quality of
				  functioning.
4. Evidence of the
				  consumer's progress, including response to services, changes in condition and
				  changes in services provided.
5.
				  Observation of changes in activity level or in physical, cognitive or emotional
				  status and details of any related referrals.
6. Case conference and consultation
				  notes.
7. Service provider notes in
				  accordance with standard professional documentation practices.
8. Reports of treatment, or other activities
				  from outside resources that may be influential in the CCS's service
				  planning.
(f) A list of
				  current prescription medication and regularly taken over the counter
				  medications. Documentation of each prescribed medication shall include all of
				  the following:
1. Name of the medication and
				  dosage.
2. Route of
				  administration.
3.
				  Frequency.
4. Duration, including
				  the date the medication is to be stopped.
5. Intended purpose.
6. Name of the prescriber. The signature of
				  prescriber is also required if the CCS prescribes medication as a
				  service.
7. Activities related to
				  the monitoring of medication including monitoring for desired responses and
				  possible adverse drug reactions, as well as an assessment of the consumer's
				  ability to self-administer medication.
7m. Medications may be administered only by a
				  physician, nurse, a practitioner, a person who has completed training in a drug
				  administration course approved by the department, or by the consumer.
8. If a CCS staff member administers
				  medications, each medication administered shall be documented on the consumer's
				  individual medication administration record (MAR) including, the time the
				  medication was administered and by whom and observation of adverse drug
				  reactions, including a description of the adverse drug reaction, the time of
				  the observation and the date and time the prescriber of the medication was
				  notified. If a medication was missed or refused by the consumer, the record
				  shall explicitly state the time that it was scheduled and the reason it was
				  missed or refused.
(g)
				  Signed consent forms for disclosure of information and for medication
				  administration and treatment.
(h)
				  Legal documents addressing commitment, guardianship, and advance
				  directives.
(i) Discharge summary
				  and any related information.
(j)
				  Any other information that is appropriate for the consumer service
				  record.