DCF 52.49(1) (1) General requirements.

DCF 52.49(1)(a) (a) A center shall provide safeguards against loss or damage of resident records by fire, theft or destruction.

DCF 52.49(1)(b) (b) Child-placing agencies and county departments shall have access to the case records of children they place.

DCF 52.49(1)(c) (c) Student interns may have access to resident records only under the supervision of center staff and after signing the confidentiality statement under s. DCF 52.12 (7) (d).

DCF 52.49(1)(d) (d) When a center closes, the center shall arrange for safe and secure storage of resident case records.

DCF 52.49(2) (2) Individual case records.

DCF 52.49(2)(a) (a) A center shall maintain a case record on a resident at the licensed location where the resident resides. A resident’s case record is confidential and shall be protected from unauthorized examination pursuant to ss. 48.78 and 938.78, Stats., or, where applicable, s. 51.30 (4), Stats., and ch. DHS 92. The center shall maintain a resident’s case record for 7 years after the resident’s discharge or until the child reaches age 19, whichever is later.

DCF 52.49(2)(b) (b) Each document in a resident’s case record shall be legible, dated and signed by the person submitting the document. A resident’s case record shall include all of the following:

DCF 52.49(2)(b)1. 1. A treatment record which contains all of the following:

DCF 52.49(2)(b)1.a. a. A history of the resident and resident’s family.

DCF 52.49(2)(b)1.b. b. The pre-admission screening required under s. DCF 52.21 (2).

DCF 52.49(2)(b)1.c. c. The written needs assessment and treatment plan required under s. DCF 52.22 (2).

DCF 52.49(2)(b)1.d. d. Treatment progress notes and implementation and review documentation required under s. DCF 52.22 (3).

DCF 52.49(2)(b)1.dm. dm. Reasonable and prudent parenting decision records required under s. DCF 52.415 (2) (e).

DCF 52.49(2)(b)1.e. e. Progress reports on residents receiving non-center professional services, as required under s. DCF 52.12 (8) (a) 3. and, if applicable, follow-along or support efforts under s. DCF 52.12 (8) (b).

DCF 52.49(2)(b)1.f. f. The aftercare plan required under s. DCF 52.23 (1) (b).

DCF 52.49(2)(b)1.g. g. The discharge summary required under s. DCF 52.23 (3).

DCF 52.49(2)(b)1.h. h. All signed written consents required under s. DHS 94.03, including consent to non-emergency use of psychotropic medications under s. DCF 52.46 (5) (c) 2. and consent for locked unit use under s. DCF 52.42 (7) (a) 3. d.

DCF 52.49(2)(b)1.i. i. Documentation of denial of resident rights and copies of the resident’s grievances and responses to them.

DCF 52.49(2)(b)1.j. j. Incident reports under ss. DCF 52.41 (1) (a) 10. and 52.42 (6).

DCF 52.49(2)(b)1.k. k. A recent photo of the resident.

DCF 52.49(2)(b)1.L. L. Any report of child abuse or neglect under s. DCF 52.12 (9).

DCF 52.49(2)(b)2. 2. A health record which contains all of the following:

DCF 52.49(2)(b)2.a. a. All health and medications information and documentation required under ss. DCF 52.45 and 52.46.

DCF 52.49(2)(b)2.b. b. Written informed consents for medical services required under s. DCF 52.21 (5).

DCF 52.49(2)(b)2.c. c. Documentation about any special nutritional or dietary needs identified by a physician or dietician, and a copy of the resident’s nutritional care plan if required under s. DCF 52.44 (2) (c).

DCF 52.49(2)(b)3. 3. The educational record required under s. DCF 52.43 (5).

DCF 52.49(2)(b)4. 4. All of the following information:

DCF 52.49(2)(b)4.a. a. The name, sex, race, religion, birth date and birth place of the resident.