Chapter DHS 92

DHS 92.05 DHS 92.05 Patient access to treatment records.

DHS 92.05(1) (1) Access during treatment.

DHS 92.05(1)(a) (a) Every patient shall have access to his or her treatment records during treatment to the extent authorized under s. 51.30 (4) (d) 1., Stats., and this subsection.

DHS 92.05(1)(b) (b) The treatment facility director or designee may only deny access to treatment records other than records of medication and somatic treatment.

DHS 92.05(1)(b)1. 1. Denial may be made only if the director has reason to believe that the benefits of allowing access to the patient are outweighed by the disadvantages of allowing access.

DHS 92.05(1)(b)2. 2. The reasons for any restriction shall be entered into the treatment record.

DHS 92.05(1)(c) (c) Each patient, patient’s guardian and parent of a minor patient shall be informed of all rights of access upon admission or as soon as clinically feasible, as required under s. 51.61 (1) (a), Stats., and upon discharge as required under s. 51.30 (4) (d) 4., Stats. If a minor is receiving alcohol or other drug abuse treatment services, the parents shall be informed that they have a right of access to the treatment records only with the minor’s consent or in accordance with 42 CFR 2.15.

DHS 92.05(1)(d) (d) The secretary of the department or designee, upon request of a director, may grant variances from the notice requirements under par. (c) for units or groups or patients who are unable to understand the meaning of words, printed material or signs due to their mental condition but these variances shall not apply to any specific patient within the unit or group who is able to understand. Parents or guardians shall be notified of any variance.

DHS 92.05(2) (2) Access after discharge for inspection of treatment records.

DHS 92.05(2)(a) (a) After discharge from treatment, a patient shall be allowed access to inspect all of his or her treatment records with one working day notice to the treatment facility, board or department, as authorized under s. 51.30 (4) (d) 3., Stats., and this subsection.

DHS 92.05(2)(b) (b) A patient making a request to inspect his or her records shall not be required to specify particular information. Requests for “all information” or “all treatment records” shall be acceptable.

DHS 92.05(2)(c) (c) When administrative rules or accreditation standards permit the treatment facility to take up to 15 days or some other specified period after discharge to complete the discharge summary, the discharge summary need not be provided until it is completed in accordance with those rules or standards.

DHS 92.05(3) (3) Copies of treatment records.

DHS 92.05(3)(a) (a) After being discharged a patient may request and shall be provided with a copy of his or her treatment records as authorized by s. 51.30 (4) (d), Stats., and as specified in this subsection.

DHS 92.05(3)(b) (b) Requests for information under this subsection shall be processed within 5 working days after receipt of the request.

DHS 92.05(3)(c) (c) A uniform and reasonable fee may be charged for a copy of the records. The fee may be reduced or waived, as appropriate, for those clients who establish inability to pay.

DHS 92.05(3)(d) (d) The copy service may be restricted to normal working hours.

DHS 92.05(4) (4) Modification of treatment records.

DHS 92.05(4)(a) (a) A patient’s treatment records may be modified prior to inspection by the patient but only as authorized under s. 51.30 (4) (d) 3., Stats., and this subsection.

DHS 92.05(4)(b) (b) Modification of a patient’s treatment records prior to inspection by the patient shall be as minimal as possible.

DHS 92.05(4)(b)1. 1. Each patient shall have access to all information in the treatment record, including correspondence written to the treatment facility regarding the patient, except that these records may be modified to protect confidentiality of other patients.

DHS 92.05(4)(b)2. 2. The names of the informants providing the information may be withheld but the information itself shall be available to the patient.

DHS 92.05(4)(c) (c) Under no circumstances may an entire document or acknowledgement of the existence of the document be withheld from the patient in order to protect confidentiality of other patients or informants.

DHS 92.05(4)(d) (d) Any person who provides or seeks to provide information subject to a condition of confidentiality shall be told that the provided information will be made available to the patient although the identity of the informant will not be revealed.

DHS 92.05(4)(e) (e) The identity of an informant providing information and to whom confidentiality has not been pledged shall be accessible to the patient as provided under this chapter.

DHS 92.05(5) (5) Correction of factual information.

DHS 92.05(5)(a) (a) Correction of factual information in treatment records may be requested by persons authorized under s. 51.30 (4) (f), Stats., or by an attorney representing any of those persons. Any requests, corrections or denial of corrections shall be in accordance with s. 51.30 (4) (f), Stats., and this section.

DHS 92.05(5)(b) (b) A written request shall specify the information to be corrected and the reason for correction and shall be entered as part of the treatment record until the requested correction is made or until the requester asks that the request be removed from the record.

DHS 92.05(5)(c) (c) During the period that the request is being reviewed, any release of the challenged information shall include a copy of the information change request.

DHS 92.05(5)(d) (d) If the request is granted, the treatment record shall be immediately corrected in accordance with the request. Challenged information that is determined to be completely false, irrelevant or untimely shall be marked through and specified as incorrect.

DHS 92.05(5)(e) (e) If the request is granted, notice of the correction shall be sent to the person who made the request and, upon his or her request, to any specified past recipient of the incorrect information.

DHS 92.05(5)(f) (f) If investigation casts doubt upon the accuracy, timeliness or relevance of the challenged information, but a clear determination cannot be made, the responsible officer shall set forth in writing his or her doubts and both the challenge and the expression of doubt shall become part of the record and shall be included whenever the questionable information is released.

DHS 92.05(5)(g) (g) If the request is denied, the denial shall be made in writing and shall include notice to the person that he or she has a right to insert a statement in the record disputing the accuracy or completeness of the challenged information included in the record.

DHS 92.05(5)(h) (h) Statements in a treatment record which render a diagnosis are deemed to be judgments based on professional expertise and are not open to challenge.

DHS 92.05 History History: Cr. Register, May, 1984, No. 341, eff. 6-1-84.

DHS 92.06 DHS 92.06 Minors and incompetents.

DHS 92.06(1) (1) Obtaining informed consent for release of information from the treatment records of minors, including developmentally disabled minors, and of incompetents and granting access by the parent or guardian and by the minor to treatment records shall be in accordance with s. 51.30 (5), Stats., and this section.

DHS 92.06(2) (2) Information may be released from the alcohol or drug abuse treatment records of a minor only with the consent of both the minor and the minor’s parent, guardian or person in the place of a parent, except that outpatient or detoxification services information, with the qualifications about these services indicated in s. 51.47 (2), Stats., shall be disclosed only with the consent of the minor provided that the minor is 12 years of age or older.

DHS 92.06 Note Note: Section 42 CFR 2.14 (b) provides that when a minor under state law can obtain treatment for alcohol abuse or drug abuse without the parent or guardian’s approval, as under s. 51.47, Stats., only the minor’s consent is required for disclosure of information from records of that treatment.

DHS 92.06(3) (3) A developmentally disabled minor aged 14 or older shall be notified of the right to file a written objection to access to treatment records by his or her parent, guardian or person in place of parent and that notice shall be documented in the treatment record.

DHS 92.06(4) (4) All sections of this chapter that are applicable to adults shall apply to any access to treatment records and disclosure of information from treatment records when the patient ceases to be a minor.

DHS 92.06 History History: Cr. Register, May, 1984, No. 341, eff. 6-1-84.

DHS 92.07 DHS 92.07 Privileged communications. Communications between a physician or psychologist and patient or between an attorney and a client shall be privileged.

DHS 92.07 Note Note: Federal regulations regarding alcohol and drug dependence treatment records do not recognize the statutory exceptions to the physician and psychologist privilege in s. 905.04, Stats., or the attorney privilege in s. 905.03, Stats., but require either informed consent or a court order under 42 CFR 2.61 to 2.67 for disclosure of confidential information.

DHS 92.07 History History: Cr. Register, May, 1984, No. 341, eff. 6-1-84.

DHS 92.08 DHS 92.08 Criminal commitments. Treatment records of persons committed under chs. 971 and 975, Stats., are covered by s. 51.30, Stats., and this chapter. Treatment records of persons sentenced to correctional facilities under criminal statutes and not receiving services from a board or a state mental health institute are not covered.

DHS 92.08 History History: Cr. Register, May, 1984, No. 341, eff. 6-1-84.

DHS 92.09 DHS 92.09 Grievance procedure. Any failure to comply with provisions of s. 51.30, Stats., or this chapter may be processed as a grievance under s. 51.61 (5), Stats., as provided in s. 51.30 (8), Stats.

DHS 92.09 History History: Cr. Register, May, 1984, No. 341, eff. 6-1-84.

DHS 92.10 DHS 92.10 Discipline of employees. Employees of the department, board, or public treatment facilities who violate requirements under s. 51.30, Stats., or this chapter may be disciplined in accordance with s. 51.30 (11), Stats.

DHS 92.10 History History: Cr. Register, May, 1984, No. 341, eff. 6-1-84.

DHS 92.11 DHS 92.11 Employee orientation. Directors and program directors shall ensure that persons whose regular duties include requesting, distributing, or granting access to treatment records are aware of their responsibility to maintain the confidentiality of information protected by this chapter and of the criminal and civil liabilities for violations of s. 51.30, Stats.

DHS 92.11 History History: Cr. Register, May, 1984, No. 341, eff. 6-1-84.

DHS 92.12 DHS 92.12 Retention periods.

DHS 92.12(1) (1) Treatment records shall be retained for at least 7 years after treatment has been completed, unless under this section they are to be retained for a longer period of time.

DHS 92.12(2) (2) In the case of a minor, records shall be retained until the person becomes 19 years of age or until 7 years after treatment has been completed, whichever is longer.

DHS 92.12(3) (3) Any record undergoing federal or state audit shall be maintained until completion of the audit.

DHS 92.12(4) (4) Records relating to legal actions shall be maintained until completion of the legal action.

DHS 92.12(5) (5) Records relating to billing or collections shall be maintained for periods of time specified in s. DHS 1.06.

DHS 92.12 History History: Cr. Register, May, 1984, No. 341, eff. 6-1-84; correction in (5) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.

DHS 92.13 DHS 92.13 Certification of compliance. Each board shall include a clause in every purchase of service contract which states that the service provider agrees to abide by the requirements of this chapter.

DHS 92.13 History History: Cr. Register, May, 1984, No. 341, eff. 6-1-84.