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Medical Records Collection, Retention, and Access in Wisconsin

        Wisconsin law requires all health care providers, including physicians, hospitals, nursing homes, home health agencies, and hospice centers, to maintain medical records for each patient, and retain those records for at least five years.1  Information required to be in a patient’s medical record differs based on the provider type.  Physicians, nursing homes, home health agencies, and hospice centers are only required to collect a patient’s identifying information as well as clinical information, such as diagnosis and treatment plan.2  Hospital patient records must include all of the latter data as well as information on the patient’s occupation, which is unique to the state of Wisconsin.3  Wisconsin law requires hospitals and ambulatory surgical centers to collect patient race and ethnicity information, and report it to the Department of Health Services.4  Treatment centers for mental illness, alcohol and drug abuse have different requirements.  The law requires treatment facilities to maintain records for each patient5 for at least seven years after the treatment has been completed, with different record retention requirements for minors.6

        Wisconsin also requires health care providers to document certain events in a patient’s medical record including a patient’s informed consent to an abortion and the existence of a do-not-resuscitate order.7

        Wisconsin law also sets forth different recordkeeping requirements for providers participating in Medicaid and Medicare.  Providers must maintain records for each Medicaid or Medicare patient treated, and must document the patient’s identifying information and clinical information.  In addition, Medicaid or Medicare participating providers must maintain financial records that include accounting records, payroll records, and billing claims forms for five years.8  Skilled nursing facilities must keep clinical records for each of their residents that contain the resident’s care plan, an assessment of their capacity, and the results of their preadmission screening.9

        The law gives patients the right to access their medical records from their health care providers and outlines permissible copying fees the provider may charge.10  Patients also have the right to request for and obtain billing information from their health care providers.11  All patients, including nursing home and hospice residents have the right to access information regarding payment and charges for services.12  All patients have a right to access their treatment records (for mental illness, alcohol and drug abuse) according to the law, but the access may be denied or limited if the provider determines that the benefits of access are outweighed by the disadvantages, unless the patient has been discharged. 13  Wisconsin also gives consumers the right to request access to recorded personal information from health insurers.  The law states that the insurer must give the consumer the requested personal information, allow the consumer to inspect or copy the information for a fee, and allow the individual the opportunity to correct, amend or modify the information.14 Employers must give former employee’s access to any of the former employee’s medical records under the employer’s control.15

 

Footnotes

  • 1. Wis. Admin. Code MED §21.03; Wis. Admin. Code DHS §124.14; Wis. Admin. Code DHS §132.45; Wis. Admin. Code DHS §133.21; Wis. Admin. Code DHS §131.33
  • 2. Wis. Admin. Code DHS §120.14; Wis. Admin. Code MED §21.03; Wis. Admin. Code DHS §132.45; Wis. Admin. Code DHS §133.21; Wis. Admin. Code DHS §131.33
  • 3. W.S.A. 146.815
  • 4. Wis. Admin. Code DHS §120.13; Wis. Admin Code DHS §120.14
  • 5. Wis. Admin. Code DHS §94.09
  • 6. Wis. Admin. Code DHS §94.12
  • 7. W.S.A. § 48.375; W.S.A. § 50.08; W.S.A. § 50.09; W.S.A. § 51.61; W.S.A. § 154.11; W.S.A. § 154.19; W.S.A. § 154.21; W.S.A. § 155.40; W.S.A. § 155.60; W.S.A. § 980.07
  • 8. Wis. Admin. Code DHS §106.02; W.S.A. 49.45(3)(f)(1)
  • 9. W.S.A. § 49.498
  • 10. Wis. Admin. Code DHS §146.83; Wis. Admin. Code DHS §131.19
  • 11. Wis. Admin. Code DHS §146.903
  • 12. Wis. Admin. Code DHS §132.31; Wis. Admin. Code DHS §94.04
  • 13. Wis. Admin. Code DHS §92.05
  • 14. Wis. Admin. Code DHS §610.70
  • 15. W.S.A. § 103.13

 

Medical Records Collection, Retention, and Access in Wisconsin

Subtopic Statute/Regulation Description
Right to access to medical records (Access by representative or other person authorized by the patient through informed consent; copying fees, or other requirements (e.g., requirement to give patient access in electronic format)) Access to patient health care records – Wis. Stat. Ann. § 146.83 Patients or individuals authorized by the patient have the right to inspect a health care provider’s records of that patient during regular...
Disclosure of personal medical information – Wis. Stat. Ann. § 610.70 The law sets forth standards that any disclosure form to any insurer authorizing the disclosure of personal medical information must follow. ...
Minors and incompetents – Wis. Admin. Code DHS §92-06 Information may be released from a minor’s drug and alcohol treatment records only with the consent of the minor and the minor’s parent...
Patient access to treatment records – Wis. Admin. Code DHS §92-05 All patients must have access to their treatment records during treatment.  A treatment facility may only deny access to treatment records if...
Patient rights in Hospices – Wis. Admin. Code DHS §131-19 A hospice must provide each patient or patient representative with a written statement of rights before services are provided.  The statement...
Records – Wis. Stat. Ann. § 51.30 Records A client may give informed consent to the disclosure of information related to their substance abuse treatment in writing provided that the...
Requirements for skilled nursing facilities – Wis. Stat. Ann. § 49.498 Requirements for Skilled Nursing Facilities This law sets forth a number of administrative requirements for skilled nursing facilities.  First,...
Violations related to patient health care records – Wis. Stat. Ann. § 146.84 Any person who negligently violates the provisions governing access to or confidentiality of patient medical records will be liable to the injured...
Wis. Stat. Ann. § 103.13 – Records open to employee Records open to employees This law requires that employers, upon request of current and former employees, allow the employee to inspect any personnel...
Content of medical record Clinical record – Wis. Admin. Code DHS §131-33 Clinical records by hospices This law describes in detail the clinical records that hospices are required to maintain for every patient.  The...
Contents of certain patient health care records – Wis. Stat. Ann. § 146.815 Patient records for inpatients must include the patient’s occupation (if possible to obtain) or the industry in which the patient was employed...
Data to be submitted by freestanding ambulatory surgery centers – Wis. Admin. Code DHS §120-13 Data to be submitted by freestanding ambulatory surgery centers This regulation requires freestanding ambulatory surgery centers to report certain...
Data to be submitted by hospitals – Wis. Admin. Code DHS §120-12 Data to be submitted by hospitals This regulation requires that hospitals submit a number of different types of data to DHS. Uncompensated health...
Do-not-resuscitate order – Wis. Stat. Ann. § 154.19 Attending physicians may issue a do-not-resuscitate order (“DNR”) if: The patient has a terminal condition, a condition that limit...
General requirements for provision of services – Wis. Admin. Code DHS §106-02 A provider providing medical assistance may only be reimbursed for covered services as long as the recipient was eligible for medical assistance when...
Medical record services – Wis. Admin. Code DHS §124-14 - Medical Record Services at Hospitals This law requires that hospitals maintain a medical record for each admitted patient, and that this record be...
Medical records – Wis. Admin. Code DHS §133-21 A home health agency must maintain a complete and accurate clinical record for each patient.  The clinical record information must be easily...
Medications and other treatment – Wis. Admin. Code DHS §94-09 All patients must be informed of their treatment plans and are encouraged to participate in their own care.  A patient has the right to refuse...
Minimum standards for patient health care records – Wis. Admin. Code DHS §21-03 A physician or physician’s assistant must maintain a health care record on every patient.  The records must be kept for at least 5 years...
Nursing Home Records – Wis. Admin. Code DHS §132-45 Nursing Home Records This law lists all the records that need to be maintained by licensed nursing homes in the state of Wisconsin.  The...
Revocation of do-not-resuscitate order – Wis. Stat. Ann. § 154.21 A patient may revoke their do-not-resuscitate order (“DNR”) by asking an emergency medical professional to remove their DNR bracelet,...
Wis. Stat. Ann. § 155.40 – Revocation of power of attorney for health care Revocation of power of attorney for health care This law allows a person to revoke his/her "power of attorney for health care" in a few different...
Destruction, storage and filing of medical records (Cross reference with Security of Health Information) Clinical record – Wis. Admin. Code DHS §131-33 Clinical records by hospices This law describes in detail the clinical records that hospices are required to maintain for every patient.  The...
Confidentiality – Wis. Admin. Code DHS §116-05 The Department must maintain the confidentiality of any information in the Wisconsin birth defect prevention and surveillance reporting system....
Medical records – Wis. Admin. Code DHS §133-21 A home health agency must maintain a complete and accurate clinical record for each patient.  The clinical record information must be easily...
Nursing Home Records – Wis. Admin. Code DHS §132-45 Nursing Home Records This law lists all the records that need to be maintained by licensed nursing homes in the state of Wisconsin.  The...
Records – Wis. Stat. Ann. § 51.30 Records A client may give informed consent to the disclosure of information related to their substance abuse treatment in writing provided that the...
Retention periods Clinical record – Wis. Admin. Code DHS §131-33 Clinical records by hospices This law describes in detail the clinical records that hospices are required to maintain for every patient.  The...
General requirements for provision of services – Wis. Admin. Code DHS §106-02 A provider providing medical assistance may only be reimbursed for covered services as long as the recipient was eligible for medical assistance when...
Medical record services – Wis. Admin. Code DHS §124-14 - Medical Record Services at Hospitals This law requires that hospitals maintain a medical record for each admitted patient, and that this record be...
Medical records – Wis. Admin. Code DHS §133-21 A home health agency must maintain a complete and accurate clinical record for each patient.  The clinical record information must be easily...
Minimum standards for patient health care records – Wis. Admin. Code DHS §21-03 A physician or physician’s assistant must maintain a health care record on every patient.  The records must be kept for at least 5 years...
Retention periods – Wis. Admin. Code DHS §92-12 Treatment records (for mental illness, and drug/alcohol abuse) must be retained for 7 years after the treatment has been completed.  For...
Medical Records Collection, Retention, and Access Data to be submitted by physician class of provider – Wis. Admin. Code DHS §120-14 Data to be submitted by physicians to DHS The Department of Health Services requires physicians to submit certain kinds of data to them on a regular...
Disclosure of personal medical information – Wis. Stat. Ann. § 610.70 The law sets forth standards that any disclosure form to any insurer authorizing the disclosure of personal medical information must follow. ...
Wis. Admin. Code DHS §34-24 - Client Service Records - Emergency Mental Health Service Programs This law requires that emergency mental health service programs maintain accurate records of all the services provided to clients, including notes...
Wis. Admin. Code DHS §35-23 - Consumer File - Outpatient Mental Health Clinics This law requires that outpatient mental health clinics maintain consumer files for each consumer who receives services from them.  The law...
Wis. Admin. Code DHS §36-18 - Consumer Service Records - Community Services for People with Mental Disorder and Substance Abuse Issues This law requires that comprehensive community services program (CCS) maintain consumer service records for each consumer in compliance with HIPAA,...
Wis. Admin. Code DHS §40-13 - Client Records - Mental Health Day Treatment Services for Children This law requires that a program that provides mental health day treatment services for children maintain a treatment record for each client.  A...
Wis. Admin. Code DHS §61-23 - Confidentiality of Records - Community Mental Health and Developmental Disabilities Services This law requires that programs that provide community mental health and developmental disabilities services maintain records on each recipient of...
Wis. Admin. Code DHS §82-09 - Records and information requests - Certified Adult Family Homes A sponsor for certified adult family homes is required to maintain a record for each resident, and these records are to be kept in a secure place...
Wis. Admin. Code DHS §83-42 - Resident Records - Community Based Residential Facilities This law requires that Community Based Residential Facilities (CBRF) maintain a record for each resident, and the law provides an extensive list of...
Wis. Admin. Code DHS §88-09 - Records - Licensed Adult Family Homes This law requires that a licensee running an adult family home maintain a record for each resident, and that these records be kept in a secure...
Wis. Stat. Ann. § 446.02 - Chiropractic Regulated This law regulates the activities of persons engaged in the practice of chiropractic.  The law requires that a chiropractor be licensed and that...
Wis. Stat. Ann. § 448.56 - Practice Requirements This law sets forth the practice requirements for persons practicing physical therapy.  The law gives details about the requirements for...
Required maintenance of medical records Medical assistance; administration – Wis. Stat. Ann. § 49.45 Medical Assistance; Administration This law sets forth the detailed instructions to the Department of Health Services on running the state's Medical...
Medical records – Wis. Admin. Code DHS §133-21 A home health agency must maintain a complete and accurate clinical record for each patient.  The clinical record information must be easily...
Nursing Home Records – Wis. Admin. Code DHS §132-45 Nursing Home Records This law lists all the records that need to be maintained by licensed nursing homes in the state of Wisconsin.  The...
Patients rights – Wis. Stat. Ann. § 51.61 Patients Rights When patients are admitted or committed, they must be informed orally and in writing of his/her rights.  These rights include...
Restrictions on use of an HIV test – Wis. Stat. Ann. § 252.15 Informed Consent Health care providers, blood banks, and plasma centers (“providers”) must take the following actions prior to...