1. (1) Coordinated plan of care.

   1. (a) A coordinated plan of care shall be developed for each client and include, whenever possible, all the following:

      1. 1. Information gathered during screening, assessment, and reassessment.
      2. 2. The circumstances resulting in the need for services including the potential for harm to self or others, including severity and lethality.
      3. 3. Services and interventions to be applied.
      4. 4. Any prescription or medication management services.
   2. (b) For clients with ongoing substance use related needs, a coordinated plan of care shall include level of care recommendations consistent with any department approved placement criteria.
   3. (c) A coordinated plan of care shall be reviewed and signed by the treatment director, clinical director, or designee within 3 business days of admission.
   4. (d) The coordinated plan of care shall be documented in writing and include a notation indicating the reason any items from par. (a) or (b) were not included.

2. (2) Discharge summary.

   1. (a) A written discharge summary for each client shall be completed and provided to the client prior to discharge. The discharge summary shall include, whenever possible, all of the following information:

      1. 1. Recommendations for care after discharge including the following:

         1. a. Care coordination efforts, including referrals or appointments made on behalf of a client.
         2. b. Information on follow-up with client by CCF staff.
         3. c. Information on accessing prescribed medications, if applicable.
      2. 2. A safety plan which includes information on available emergency mental health services in the client’s geographic area of the client’s current residence or intended residence.
      3. 3. The client’s legal status and condition at discharge.
      4. 4. Department approved placement criteria, as applicable and necessary for clients being discharged to a facility requiring this.
      5. 5. A crisis plan for all clients admitted for 24 hours or more.
   2. (b) The discharge summary shall be reviewed and signed by the treatment director, clinical director, or designee within 3 days of discharge, not including Saturdays, Sundays, or legal holidays.
   3. (c) The discharge summary shall include a notation indicating the reason any items from par. (a) were not included.
   4. (d) The discharge summary shall be provided to the county of responsibility and external providers as applicable and with the client’s written consent.

3. (3) Service notes.

   1. (a) Staff providing services shall document the content of contacts with clients or collateral sources and clinical observations as it relates to a client’s care and treatment.
   2. (b) Service notes shall include documentation of services, interventions, or treatment provided and client response to those services.

History

History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (1) (d), (2) (c) made under s. 35.17, Stats., Register February 2026 No. 842.