DHS 75.24(11)(d)3.g.g. Withdrawal and overdose history.
DHS 75.24(11)(d)4.4. Documentation about the current mental and physical health status of the patient.
DHS 75.24(11)(d)5.5. Psychosocial history information shall include all of the following areas that relate to the patient’s presenting problem:
DHS 75.24(11)(d)5.a.a. Family.
DHS 75.24(11)(d)5.b.b. Significant relationships.
DHS 75.24(11)(d)5.c.c. Legal.
DHS 75.24(11)(d)5.d.d. Social.
DHS 75.24(11)(d)5.e.e. Financial.
DHS 75.24(11)(d)5.f.f. Education.
DHS 75.24(11)(d)5.g.g. Employment.
DHS 75.24(11)(d)5.h.h. Treatment history.
DHS 75.24(11)(d)5.i.i. Other factors that appear to have a relationship to the patient’s substance use and physical and mental health.
DHS 75.24(11)(d)6.6. The clinical assessment shall include any collateral information gathered during the clinical assessment. Collateral information may include one of more of the following:
DHS 75.24(11)(d)6.a.a. Review of Wisconsin Prescription Drug Monitoring Program database.
DHS 75.24(11)(d)6.b.b. Records of the patient’s legal history.
DHS 75.24(11)(d)6.c.c. Information from referral sources.
DHS 75.24(11)(d)6.d.d. Consultation with the patient’s physician or other medical or behavioral health provider.
DHS 75.24(11)(d)6.e.e. Consultation with department of corrections or child protective services when applicable.
DHS 75.24(11)(d)6.f.f. Information from the patient’s family or significant others.
DHS 75.24(11)(d)6.g.g. Results of toxicology testing.
DHS 75.24(11)(d)7.7. Level of care recommendation based on ASAM or other department-approved placement criteria.
DHS 75.24(11)(e)(e) If no collateral information is obtained to inform the assessment, the service shall document the reason for not including collateral information.
DHS 75.24(11)(f)(f) The clinical staff’s recommendations for treatment shall be included in a summary of the assessment that is consistent with diagnosis and level of care placement criteria.
DHS 75.24(11)(g)(g) If an assessing substance abuse counselor identifies symptoms of a mental health disorder during the assessment process, the substance abuse counselor shall refer the individual to an appropriately credentialed provider for a comprehensive mental health assessment, unless the substance abuse counselor is also a licensed mental health professional.
DHS 75.24(11)(h)(h) If the assessing clinical staff identifies symptoms of a physical health problem during the assessment process, the service shall refer the individual for a physical health assessment conducted by medical personnel.
DHS 75.24(11)(i)(i) If the assessing clinical staff identifies that an individual is pregnant at the time of the assessment, the service shall make a referral for prenatal care or ensure that the patient is already receiving prenatal care, and document efforts to coordinate care with prenatal care providers.
DHS 75.24(11)(j)(j) In the event that the assessed level of care is not available, a service shall:
DHS 75.24(11)(j)1.1. Document accurately the level of care indicated by the clinical assessment.
DHS 75.24(11)(j)2.2. Indicate on the treatment plan what alternative level of care is available or agreed upon.