DHS 40.15(2)
(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.
DHS 40.15(4)
(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.
DHS 40.15(5)
(5)
Client treatment record. A treatment file or electronic record shall include all of the following:
DHS 40.15(5)(b)
(b) Notes and reports made while screening the youth for admission.
DHS 40.15(5)(f)
(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.
DHS 40.15(5)(g)
(g) Results of additional evaluations and other assessments performed while the youth is enrolled in the program.
DHS 40.15(5)(i)
(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.
DHS 40.15(5)(j)
(j) Any recommended changes or improvements of the treatment plan resulting from clinical collaboration or clinical oversight.
DHS 40.15(5)(k)
(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).
DHS 40.15(5)(m)
(m) Documentation of transition services and discharge planning, including involuntary discharge.
DHS 40.15(5)(n)
(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.
DHS 40.15(5)(o)
(o) Records of referrals of the youth to outside resources.
DHS 40.15(5)(p)
(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.
DHS 40.15(5)(r)
(r) Care coordination provided with the youth or legal representative.
DHS 40.15(5)(s)
(s) Any other information that is appropriate for the youth file.
DHS 40.15(6)(a)
(a) Programs may maintain treatment records electronically if the program has a written policy describing the records and the authentication and security policy.
DHS 40.15(6)(b)
(b) Electronic transmission of information from treatment records to information systems outside the program shall not occur without voluntary written consent for disclosure from the youth or legal representative per s.
51.30, Stats., or as otherwise provided by law.
DHS 40.15(7)
(7) Education records. Education records of a youth shall be kept separate from the youth's treatment record, and shall comply with federal and state statutes and regulations relating to educational records.
DHS 40.15 Note
Note: Federal and state statutes and regulations relating to educational records are found in
20 USC 1232g and 34 CFR Pt. 99, and s.
118.125, Stats.
DHS 40.15(8)
(8) Maintenance and security. The program director is responsible for the maintenance and security of client treatment records.
DHS 40.15(9)
(9) Disposition upon program closing. A program shall establish a written policy for maintenance and disposition of records, in accordance with s.
DHS 92.12, in the event the program closes.
DHS 40.15 History
History: CR 19-018: cr.
Register June 2020 No. 774, eff. 7-1-20; correction in (3), (5) (k) made under s.
35.17, Stats.,
Register June 2020 No. 774.
DHS 40.16
DHS 40.16
Client rights. All programs shall comply with s.
51.61, Stats., and ch.
DHS 94 on the rights of clients.
DHS 40.16 History
History: CR 19-018: cr.
Register June 2020 No. 774, eff. 7-1-20.
DHS 40.17(1)(1)
Outcomes. A program shall at least annually evaluate the effectiveness of services provided to its clients by doing all of the following:
DHS 40.17(1)(a)
(a) Preparing a statement of the program's clinical and support services outcomes for youth stated in objectively measurable terms.
DHS 40.17(1)(b)
(b) Preparing and making available to the public an annual report of youth service outcomes.
DHS 40.17(2)(a)(a) In addition to the outcome evaluation under sub.
(1), a program shall arrange for an annual review of its program operations, including all of the following:
DHS 40.17(2)(a)1.
1. Appropriateness of referrals, admissions, and clients' length of stay.
DHS 40.17(2)(a)2.
2. Efficiency of procedures for conducting assessments and developing treatment plans.
DHS 40.17(2)(a)3.
3. Use of a supportive and trauma-informed treatment milieu, and improving quality of care and safety of youth.
DHS 40.17(2)(a)4.
4. The use of emergency safety interventions, including an aggregate review of all incidents of seclusion and physical restraint, to assure that the wellbeing of youth is safeguarded and that youth rights are protected.
DHS 40.17(2)(a)6.
6. Functionality of care coordination and integration with other services.
DHS 40.17(2)(b)
(b) The review of program operations may be conducted by an advisory committee established by the program, an already established quality assurance and performance improvement committee, by a committee of the board of directors of the facility operating the program, or by any other appropriate and objective body. The committee shall include the program director and clinical coordinator, additional program staff members as appropriate, and whenever possible include parents and community members.
DHS 40.17(2)(c)
(c) A summary of the review of program operations shall be appended to the annual report prepared under sub.
(1) (b) and made available to department staff upon request.
DHS 40.17 History
History: CR 19-018: cr.
Register June 2020 No. 774, eff. 7-1-20; correction in (2) (c) made under s.
13.92 (4) (b) 7., Stats.,
Register January 2021 No. 781.
DHS 40.18
DHS 40.18
Death Reporting. Each program shall adopt written policies and procedures for reporting to the department deaths of youth no later than 24 hours after a death due to suicide, psychotropic medications, or use of physical restraints, as required by s.
51.64 (2), Stats.
DHS 40.18 History
History: CR 19-018: cr.
Register June 2020 No. 774, eff. 7-1-20.
