Community Grievance Decision Digest

Documentation Requirements

The decision summaries regarding this law may be found in the document:
Community Grievance Decision Digest: Decisions. (PDF, 512KB)

THE LAW:

“The treatment facility shall maintain a patient treatment record for each patient which shall include:

(a) A specific statement of the diagnosis and an explicit description of the behaviors and other signs or symptoms exhibited by the patient;

(b) A specific statement of the diagnosis and an explicit description of the behaviors and other signs or symptoms exhibited by the patient;

(c) Documentation of the emergency when emergency treatment is provided to the patient; and

(d) Clear documentation of the reasons and justifications for the initial use of medications and for any changes in the prescribed medication regimen.

(e) Documentation that is specific and objective and that adequately explains the reasons for any conclusions or decisions made regarding the patient.”

DHS 94.09(6), Wis. Admin. Code [Emphasis added.]

Last Updated: November 10, 2009