Chapter DHS 63

DHS 63.15(1) (1) A CSP shall maintain a treatment record for each client. The record shall include information that is sufficiently detailed to enable a person not familiar with the CSP to identify the types of services the client has received.

DHS 63.15(2) (2) The CSP director is responsible for the maintenance and security of client treatment records.

DHS 63.15(3) (3) Client treatment records shall be maintained in a central location.

DHS 63.15(4) (4) Client treatment records shall be kept confidential and safeguarded as required under s. 51.30, Stats., and ch. DHS 92.

DHS 63.15(5) (5) The treatment recordkeeping format shall provide for consistency within the CSP and shall facilitate information retrieval. Treatment records shall include:

DHS 63.15(5)(a) (a) Results of all examinations, tests and other assessment information;

DHS 63.15(5)(b) (b) Reports from referring sources;

DHS 63.15(5)(c) (c) Treatment and service plans, except for records of hospital emergency services;

DHS 63.15(5)(d) (d) Medication records, which shall document ongoing monitoring of administration of medications and the detection of adverse drug reactions. All medication orders in the client treatment record 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;

DHS 63.15(5)(e) (e) Records of referrals of the client to outside resources;

DHS 63.15(5)(f) (f) Reports from outside resources;

DHS 63.15(5)(g) (g) Multidisciplinary case conference and consultation notes;

DHS 63.15(5)(h) (h) Consent for disclosure of information release forms;

DHS 63.15(5)(i) (i) Progress notes which shall document the location where the service was provided; and

DHS 63.15(5)(j) (j) Discharge documentation.

DHS 63.15(6) (6) There shall be a policy governing the disposal of client records.

DHS 63.15(7) (7) There shall be a policy concerning the disposition of client records in the event of the CSP closing.

DHS 63.15 History History: Cr. Register, April, 1989, No. 400, eff. 5-1-89; correction in (4) made under s. 13.93 (2m) (b) 7., Stats., Register December 2004 No. 588; correction in (4) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.

DHS 63.16 DHS 63.16 Discharge. Documentation by the client’s case manager, clinical coordinator and psychiatrist of a client’s discharge from a CSP shall be entered in the client’s treatment record within one week after termination of treatment or services. Documentation of discharge shall include:

DHS 63.16(1) (1) The reasons for discharge;

DHS 63.16(2) (2) The client’s status and condition at discharge;

DHS 63.16(3) (3) A written final evaluation summary of the client’s progress toward the goals set forth in the treatment plan;

DHS 63.16(4) (4) A plan developed, in conjunction with the client, for care after discharge and for follow-up; and

DHS 63.16(5) (5) The signature of the case manager, clinical coordinator and psychiatrist.

DHS 63.16 History History: Cr. Register, April, 1989, No. 400, eff. 5-1-89.

DHS 63.17 DHS 63.17 Program evaluation.

DHS 63.17(1) (1) Each CSP shall have an evaluation plan, which shall include:

DHS 63.17(1)(a) (a) A statement of the program’s objectives. The objectives shall relate directly to the program’s clients or target population;

DHS 63.17(1)(b) (b) Measurable criteria to be applied in determining whether or not the objectives under par. (a) are achieved;

DHS 63.17(1)(c) (c) Methods for documenting achievements not related to the program’s stated objectives; and

DHS 63.17(1)(d) (d) Methods for assessing the effective utilization of staff and resources toward the attainment of the objectives.

DHS 63.17(2) (2) In addition to the evaluation plan required under sub. (1), a CSP shall have a system for regular review that is designed to evaluate the appropriateness of admissions to the program, length of stay, treatment or service plans, discharge practices and other factors that may contribute to effective use of the program’s resources.

DHS 63.17(3) (3) An annual report on the program’s progress in meeting its objectives shall be prepared, distributed to interested persons and made available to the department upon request.

DHS 63.17(4) (4) The CSP’s governing body or appropriate authority shall review the annual report.

DHS 63.17 History History: Cr. Register, April, 1989, No. 400, eff. 5-1-89.