1. (1) Records required.

   1. (a) The clinic shall maintain a consumer file for each consumer who receives outpatient mental health services. Each consumer file shall be arranged in a format that provides for consistent recordkeeping that facilitates accurate and efficient retrieval of record information. All entries in the consumer file shall be factual, accurate, legible, permanently recorded, dated, and authenticated with the signature and license or title of the person making the entry. Treatment records contained in a consumer file are confidential to the extent required under s. 51.30, Stats. An electronic representation of a person’s signature may be used only by the person who makes the entry. The clinic shall possess a statement signed by the person, which certifies that only that person shall use the electronic representation via use of a personal password. Each consumer file shall include accurate documentation of all outpatient mental health services received including all of the following:

      1. 1. Results of each assessment conducted.
      2. 2. Initial and updated treatment plans.
      3. 3. The recommendation or prescription for psychotherapy.
      4. 4. For consumers who are diagnosed with substance abuse disorder, a completed copy of the most current approved placement criteria summary if required by s. DHS 35.16 (5).
      5. 5. Documentation of referrals of the consumer to outside resources.
      6. 6. Descriptions of significant events that are related to the consumer’s treatment plan and contribute to an overall understanding of the consumer’s ongoing level and quality of functioning.
      7. 7. Progress notes, which shall include documentation of therapeutic progress, functional status, treatment plan progress, symptom status, change in diagnosis, and general management of treatment.
      8. 8. Any recommended changes or improvement of the treatment plan resulting from clinical collaboration or clinical supervision.
      9. 9. Signed consent forms for disclosure of information and for medication administration and treatment, and court orders, if any.
      10. 10. A listing of medications prescribed by staff prescribers, and a medication administration record if staff dispenses or administers medications to the consumer.
      11. 11. Discharge summary and any related information.
      12. 12. Notice of involuntary discharge, if applicable.
      13. 13. Any other information that is appropriate for the consumer file.
   2. (b) Clinics may keep composite consumer files of a family in treatment as a unit. When information is released, provisions shall be made for individual confidentiality pursuant to s. 51.30, Stats., and ch. DHS 92.

2. (2) Confidentiality. Treatment records shall be kept confidential as required under s. 51.30, Stats., ch. DHS 92, and 45 CFR Parts 160, 162 and 164, and 42 CFR Part 2 in a designated place in each clinic office at which records are stored that is not accessible to consumers or the public but is accessible to appropriate staff members at all times.

   Note: If notes or records, recorded in any medium, maintained for personal use by an individual providing treatment services are available to others, the notes or records become part of the treatment records. See s. 51.30 (1) (b), Stats., and ss. DHS 92.02 (16) and 92.03 (1) (b).

3. (3) Transferring treatment records. Upon written request of a consumer or former consumer or, if required, that person’s legal representative, the clinic shall transfer to another licensed treatment professional, clinic or mental health program or facility the treatment records and all other information in the consumer file necessary for the other licensed treatment professional, clinic or mental health program or facility to provide further treatment to the consumer or former consumer.

4. (4) Retention and disposal.

   1. (a) The clinic shall implement a written policy governing the retention of treatment records that is in accordance with s. DHS 92.12 and any other applicable laws.
   2. (b) Upon termination of a staff member’s association with the clinic, the treatment records for which the staff member was responsible shall remain in the custody of the clinic.

5. (5) Electronic record-keeping systems.

   1. (a) Clinics may maintain treatment records electronically if the clinic has a written policy describing the record and the authentication and security policy.

   2. (b) Electronic transmission of information from treatment records to information systems outside the outpatient mental health clinic may not occur without voluntary written consent of the consumer unless the release of confidential treatment information is permitted under s. 51.30, Stats., or other applicable law.

      Note: Transmission of information must comply with 45 CFR parts 160, 162, and 164, s. 51.30, Stats., and ch. DHS 92.

   3. (c) If treatment records are kept electronically, the confidentiality of the treatment records shall be maintained as required under subs. (2) to (4). A clinic shall maintain a paper or electronic back-up system for any treatment records maintained electronically.

      Note: If notes or records, recorded in any medium, maintained for personal use by an individual providing treatment services are available to others, the notes or records become part of the treatment records. See s. 51.30 (1) (b), Stats., and ss. DHS 92.02 (16) and 92.03 (1) (b).

History

History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.