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Wis. Admin. Code DHS §40-13 - Client Records - Mental Health Day Treatment Services for Children

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This law requires that a program that provides mental health day treatment services for children maintain a treatment record for each client.  A treatment record must include documentation of all services provided to client, all activities the client participated in, and all other interventions with or on behalf of the client, and the improvement/regression/changes exhibited by the client while in the program. 
Each treatment record must include a number of materials, including but not limited to: initial referral materials; notes and reports made while screening client for admission; a copy of the letter accepting/rejecting referral; report of multidisciplinary assessment of the client and his/her family; reports and other evaluations of client and family; results of additional evaluations while client is enrolled in the program; treatment plan; documentation of services provided; written summaries of reviews of treatment plan; documentation of discharge planning; medication records; referral records of client; written consent or court order or country department authorization to admission and any consent for disclosure of information; records of lodged grievances; treatment plan case conference notes.
This law requires that the client’s education records be kept separate from the treatment record.  The law makes the program director responsible for maintenance and security of these records.  The records must be maintained in a central location suitable for efficient record retrieval.  The treatment records must be kept confidential and must be safeguarded.  The program must establish a plan for the maintenance and disposal of records in case the program closes.

Current as of June 2015