1. (1) The substance use overdose treatment program shall maintain in a central location a service record for each participant. Each record shall include sufficient information to demonstrate that the program has an accurate understanding of the participant, the participant’s needs, desired outcomes, and progress toward goals. Entries shall be legible, dated and signed.

2. (2) Each participant 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 participant’s record:

   1. (a) Results of the assessment.
   2. (b) Initial and updated plans.

   3. (c) Treatment and service delivery information, including all of the following:

      1. 1. Service provider notes in accordance with standard professional documentation practices.
      2. 2. Records of referrals of the participant to outside resources.
      3. 3. Documentation of the participant’s progress toward goals and changes in services provided.
      4. 4. Discharge summary and any related information.
      5. 5. Any other information that is appropriate for the participant service record.
3. (3) Peer recovery support service delivery information shall be kept in accordance with s. DHS 72.07.
4. (4) Each participant service record shall be maintained pursuant to the confidentiality requirements under the health insurance portability and accountability act of 1996, 42 USC 1320d-2, s. 51.30, Stats., ch. DHS 92 and, if applicable, 42 CFR Part 2. Electronic records and electronic signatures shall meet the requirements in 45 CFR 164 Subpart C.

History

History: CR 24-081: cr. Register September 2025 No. 837, eff. 10-1-25; correction in (4) made under s. 35.17, Stats., Register September 2025 No. 837.