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 medications or other treatments.  A patient who does not agree with his or her treatment plan may receive a secondary consultation.  An involuntary patient can receive a secondary consultation at no charge, while other patients may have to pay for their own secondary opinions. 

No medications may be given or treatments performed on a patient unless the patient gives informed consent, except in emergency situations to prevent physical self harm or harm to others.  If a patient is found too incompetent to give informed consent, the patient’s guardian must give his or her consent.  For a patient who is a minor, informed consent of the parent or guardian is needed.  If patient is a minor and is 14 years old or older, both the patient and parent’s informed consent is required.  A voluntary patient may refuse treatment or medications at any time, for any reason except in emergencies. 

A treatment facility must maintain a record for each patient treated.  The record must include:

• A statement of the diagnosis;
• Signs and symptoms;
• Emergency treatment provided;
• Documentation of the reasons for initial medication use;
• Documentation that explains any decisions made about the patient.

Physicians that order or change patient medications must ensure that other providers are notified of the change.  When changing or ordering medications, the physician must review the medications and document the review in the patient’s medical record.