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 the provider believes the benefits to access are outweighed by the disadvantages.  Any reasons for denying access must be noted in the record.

All patients or patient’s guardians must be notified of their rights in the facility.  The notice requirement does not apply in special circumstances if the patient is unable to understand words or printed materials due to a mental condition.  Guardians of minors being treated for alcohol or drug abuse may only have access to the minor’s treatment records with the minor’s consent or as required by law.   

After discharge, a patient is allowed to inspect his or her treatment records with one day’s notice to the treatment facility.  After discharge, a patient has a right to a copy of his or her treatment record.  Requests must be processed within 5 days after receiving the request.  Treatment facilities may charge a reasonable fee for the copies.  The fee may be waived for patients who are unable to pay. 

A patient’s treatment record may be modified prior to inspection by the patient.  Any such modification must be very minimal.  A complete document may not be withheld from a patient in order to protect other patients’ confidentiality. 

A factual correction of information in a treatment record may be requested by the patient or an attorney.  This must be done through a written request that specifies the requested correction and the reason for the correction, and must be put in the treatment record.  If the request is granted, notice of the correction must be sent to the requestor.  If the request is denied, a written denial must be sent to the requestor.  Diagnoses in the treatment record are judgments based on professional expertise and not subject to challenges.