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 requires that these records be arranged in a format that allows for efficient retrieval and that the records themselves be accurate, legible, dated and authenticated.  The law states that treatment records are confidential.  The law requires that each consumer file include a number of documents, including but not limited to: results of assessments, treatment plans, recommendations, prescription for psychotherapy, referrals of consumer to outside resources, progress notes, signed consent forms, listing of prescribed medications, discharge summary.
 
The law allows clinics to keep a composite consumer file for a family in treatment as a unit.  The law requires that the clinic transfer treatment records to another licensed professional or clinic upon receiving consumer’s written request.  The law requires that clinics implement a policy governing retention of treatment records.  Further, clinics are allowed to maintain treatment records electronically, as long as they have a written policy describing the authentication and security policy.  Clinics are required to maintain a paper/electronic back-up for electronic treatment records.