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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