All medication orders. These shall specify the name of the medication, dose, route of administration, frequency of administration, person administering and name of the physician who prescribed the medication.
Reports from referring sources, each to include the name of the referral source, the date of the report and the date the patient was referred to the service.
Records of referral by the service, including documentation that referral follow-up activities occurred.
Multi-disciplinary case conference and consultation notes signed by the primary counselor.
Correspondence relevant to the patient's treatment, including all letters and dated notations of telephone conversations.
Consent forms authorizing disclosure of specific information about the patient.
Progress notes, including staffings, in accordance with the service's policies and procedures.
A record of services provided that includes documentation of all case management, education, services and referrals.
Staffing notes signed by the primary counselor and the clinical supervisor, and by the mental health professional if the patient is dually diagnosed.
Documentation of transfer from one level of care to another. Documentation shall identify the applicable criteria from approved placement criteria, and shall include the dates the transfer was recommended and initiated.
A service shall have policies and procedures to ensure the security and confidentiality of all case records when clinical supervision is provided off site.
DHS 75.03 Note
Note: An example of when clinical supervision may be provided off site is a staffing held at a central location attended by counselors from one or more branch clinics.
If the service discontinues operations or is taken over by another service, records containing patient identifying information may be turned over to the replacement service or any other service provided the patient consents in writing. If no patient consent is obtained, the records shall be sealed and turned over to the department to be retained for 7 years and then destroyed.
A patient's case record shall be maintained by the service for a period of 7 years from the date of termination of treatment or service.
A service is the custodian and owner of the patient file and may release information only in compliance with sub. (7)
(9) Case records for persons receiving emergency services. DHS 75.03(9)(a)(a)
A service shall keep a case record for every person requesting or receiving emergency services under s. DHS 75.06
, except where the only contact made is by telephone.
A case record prepared under this subsection shall comply with requirements under s. DHS 124.14
, if the service is operated by a hospital, or include all of the following:
Time of the individual's arrival, means of arrival and method of transportation.
Pertinent history of the problem, including details of first aid or emergency care given to the individual before being seen by the emergency service.
Results of emergency screening, diagnosis or other assessment completed.
Final disposition, including instructions given to the individual regarding necessary follow-up care.
Record of services provided, which shall be signed by the physician in attendance when medical diagnosis or treatment has been provided.
Name, address and phone number of a person to be notified in case of an emergency provided that there is a release of information signed by the patient that enables the agency to contact that person, unless the person is incapacitated and is unable to sign a release of information.
A service shall complete withdrawal screening for a patient who is currently experiencing withdrawal symptoms or who presents the potential to develop withdrawal symptoms.
Acceptance of a patient for substance abuse services shall be based on a written screening procedure and the application of approved patient placement criteria. The written screening procedure shall clearly state the criteria for determining eligibility for admission.
All substance abuse screening procedures shall include the collection of data relating to impairment due to substance use consistent with the WI-UPC, ASAM patient placement criteria or other similar patient placement criteria approved by the department.
Basis for admission.
Admission of an individual to a service for treatment shall be based upon an intake procedure that includes screening, placement, initial assessment and required administrative tasks.
Policies and procedures for intake.
A service shall have written policies and procedures to govern the intake process, including all of the following:
A description of the types of information to be obtained from an applicant before admission.
A written consent to treatment statement attached to the initial service plan, which shall be signed by the prospective patient before admission is completed.
A method of informing the patient about and ensuring that the patient understands all of the following, and for obtaining the patient's signed acknowledgment of having been informed and understanding all of the following:
Patient rights and the protection of privacy provided by the confidentiality laws.
Service regulations governing patient conduct, the types of infractions that result in corrective action or discharge from the service and the process for review or appeal.
Information about the cost of treatment, who will be billed and the accepted methods of payment if the patient will be billed.
The initial assessment shall include all of the following:
Available information regarding the patient's family, significant relationships, legal, social and financial status, treatment history and other factors that appear to have a relationship to the patient's substance abuse and physical and mental health.
Documentation of how the information identified in subds. 1.
relate to the patient's presenting problem.
Documentation about the current mental and physical health status of the patient.
Preliminary service plan.
A preliminary service plan shall be developed, based upon the initial assessment.
Explanation of initial assessment and service plan.
The initial assessment and preliminary service plan shall be clearly explained to the patient and, when appropriate, to the patient's family members during the intake process.
Information and referral relating to communicable diseases.
The service shall provide patients with information concerning communicable diseases, such as sexually transmitted diseases (STDs), hepatitis B, tuberculosis (TB), and human immunodeficiency virus (HIV), and shall refer patients with communicable disease for treatment when appropriate.
Staff of a service shall assess each patient through screening interviews, data obtained during intake, counselor observation and talking with people who know the patient. Information for the assessment shall include all of the following:
The substance abuse counselor's evaluation of the patient and documentation of psychological, social and physiological signs and symptoms of substance abuse and dependence, mental health disorders and trauma, based on criteria in DSM-IV.
The summarized results of all psychometric, cognitive, vocational and physical examinations taken for, or as a result of, the patient's enrollment into treatment.
The counselor's recommendations for treatment shall be included in a written case history that includes a summary of the assessment information leading to the conclusions and outcomes determined from the counselor's evaluation of the patient's problems and needs.
If a counselor identifies symptoms of a mental health disorder and trauma in the assessment process, the service shall refer the individual for a mental health assessment conducted by a mental health professional.
If a counselor identifies symptoms of physical health problems in the assessment process, the service shall refer the individual for a physical health assessment conducted by medical personnel.
Initial assessment shall be conducted for treatment planning. The service shall implement an ongoing process of assessment to ensure that the patient's treatment plan is modified if the need arises as determined through a staffing at least every 30 days.
Basis and signatures.
A service shall develop a treatment plan for each patient. A patient's treatment plan shall be based on the assessment under sub. (12)
and a discussion with the patient to ensure that the plan is tailored to the individual patient's needs. The treatment plan shall be developed in collaboration with other professional staff, the patient and, when feasible, the patient's family or another person who is important to the patient, and shall address culture, gender, disability, if any, and age-responsive treatment needs related to substance use disorders, mental disorders and trauma. The patient's participation in the development of the treatment plan shall be documented. The treatment plan shall be reviewed and signed first by the clinical supervisor and the counselor and secondly reviewed and signed by the patient and the consulting physician.
The treatment plan shall describe the patient's individual or distinct problems and specify short and long-term individualized treatment goals that are expressed in behavioral and measurable terms, and are explained as necessary in a manner that is
understandable to the patient.
The treatment plan shall specify the treatment, rehabilitation, and other therapeutic interventions and services to reach the patient's treatment goals.
The treatment plan shall describe the criteria for discharge from services.
The treatment plan shall provide specific goals for treatment of dual diagnosis for those who are identified as being dually diagnosed, with input from a mental health professional.
Tasks performed in meeting the goals shall be reflected in progress notes and in the staffing reports.
A patient's treatment plan constitutes a treatment contract between the patient and the service.
A patient's treatment plan shall be reviewed at regular intervals as identified in sub. (14)
and modified as appropriate with date and results documented in the patient's case record through staffing reports.
Staffing shall be completed for each patient and shall be documented in the patient's case record as follows:
Staffing for patients in an outpatient treatment service who attend treatment sessions one day per week or less frequently shall be completed at least every 90 days.
Staffing for patients who attend treatment sessions more frequently than one day per week shall be completed at least every 30 days.
A staffing report shall include information on treatment goals, strategies, objectives, amendments to the treatment plan and the patient's progress or lack of progress, including applicable criteria from the approved placement criteria being used to recommend the appropriate level of care for the patient.