Chapter DHS 132

DHS 132.44 Note Note: For recordkeeping requirements for all orientation and inservice programs, see s. DHS 132.45 (6) (f).

DHS 132.44 History History: Cr. Register, July, 1982, No. 319, eff. 8-1-82; r. and recr. (2) (a) and am. (4), Register, January, 1987, No. 373, eff. 2-1-87; CR 04-053: renum. (1) (c) to be (1) (b) Register October 2004 No. 586, eff. 11-1-04; CR 06-053: r. (3) Register August 2007 No. 620, eff. 9-1-07.

DHS 132.45 DHS 132.45 Records.

DHS 132.45(1) (1) General. The administrator or administrator’s designee shall provide the department with any information required to document compliance with ch. DHS 132 and ch. 50, Stats., and shall provide reasonable means for examining records and gathering the information.

DHS 132.45(2) (2) Personnel records. A separate record of each employee shall be maintained, be kept current, and contain sufficient information to support assignment to the employee’s current position and duties.

DHS 132.45(3) (3) Medical records — staff. Duties relating to medical records shall be completed in a timely manner.

DHS 132.45(4) (4) Medical records — general.

DHS 132.45(4)(c) (c) Unit record. A unit record shall be maintained for each resident and day care client.

DHS 132.45(4)(f) (f) Retention and destruction.

DHS 132.45(4)(f)1. 1. An original medical record and legible copy or copies of court orders or other documents, if any, authorizing another person to speak or act on behalf of this resident shall be retained for a period of at least 5 years following a resident’s discharge or death when there is no requirement in state law. All other records required by this chapter shall be retained for a period of at least 2 years.

DHS 132.45(4)(f)2. 2. A facility shall arrange for the storage and safekeeping of records for the periods and under the conditions required by this paragraph in the event the facility closes.

DHS 132.45(4)(f)3. 3. If the ownership of a facility changes, the medical records and indexes shall remain with the facility.

DHS 132.45(4)(g) (g) Records documentation.

DHS 132.45(4)(g)1. 1. All entries in medical records shall be accurate, legible, permanently recorded, dated, and authenticated with the name and title of the person making the entry.

DHS 132.45(4)(g)2. 2. A rubber stamp reproduction or electronic representation of a person’s signature may be used instead of a handwritten signature, if:

DHS 132.45(4)(g)2.a. a. The stamp or electronic representation is used only by the person who makes the entry; and

DHS 132.45(4)(g)2.b. b. The facility possesses a statement signed by the person, certifying that only that person shall possess and use the stamp or electronic representation.

DHS 132.45(4)(g)3. 3. Symbols and abbreviations may be used in medical records if approved by a written facility policy which defines the symbols and abbreviations and which controls their use.

DHS 132.45(5) (5) Medical records — content. Except for persons admitted for short-term care, to whom s. DHS 132.70 (7) applies, each resident’s medical record shall contain:

DHS 132.45(5)(a) (a) Identification and summary sheet.

DHS 132.45(5)(b) (b) Physician’s documentation.

DHS 132.45(5)(b)1. 1. An admission medical evaluation by a physician or physician extender, including:

DHS 132.45(5)(b)1.a. a. A summary of prior treatment;

DHS 132.45(5)(b)1.b. b. Current medical findings;

DHS 132.45(5)(b)1.c. c. Diagnoses at the time of admission to the facility;

DHS 132.45(5)(b)1.d. d. The resident’s rehabilitation potential;

DHS 132.45(5)(b)1.e. e. The results of the physical examination required by s. DHS 132.52 (3); and

DHS 132.45(5)(b)1.f. f. Level of care;

DHS 132.45(5)(b)2. 2. All physician’s orders including, when applicable, orders concerning:

DHS 132.45(5)(b)2.a. a. Admission to the facility as required by s. DHS 132.52 (2) (a);

DHS 132.45(5)(b)2.b. b. Medications and treatments as specified by s. DHS 132.60 (5);

DHS 132.45(5)(b)2.c. c. Diets as required by s. DHS 132.63 (4);

DHS 132.45(5)(b)2.d. d. Rehabilitative services as required by s. DHS 132.64 (2);

DHS 132.45(5)(b)2.e. e. Limitations on activities;

DHS 132.45(5)(b)2.f. f. Restraint orders as required by s. DHS 132.60 (6); and

DHS 132.45(5)(b)2.g. g. Discharge or transfer as required by s. DHS 132.53;

DHS 132.45(5)(b)3. 3. Physician progress notes following each visit.

DHS 132.45(5)(b)4. 4. Annual physical examination, if required; and

DHS 132.45(5)(b)5. 5. Alternate visit schedule, and justification for such alternate visits.

DHS 132.45(5)(c) (c) Nursing service documentation.

DHS 132.45(5)(c)1. 1. A history and assessment of the resident’s nursing needs as required by s. DHS 132.52;

DHS 132.45(5)(c)2. 2. Initial care plan as required by s. DHS 132.52 (4), and the care plan required by s. DHS 132.60 (8);

DHS 132.45(5)(c)3. 3. Nursing notes are required as follows:

DHS 132.45(5)(c)3.a. a. For residents requiring skilled care, a narrative nursing note shall be required as often as needed to document the resident’s condition, but at least weekly; and

DHS 132.45(5)(c)3.b. b. For residents not requiring skilled care, a narrative nursing note shall be required as often as needed to document the resident’s condition, but at least every other week;

DHS 132.45(5)(c)4. 4. In addition to subds. 1., 2., and 3., nursing documentation describing:

DHS 132.45(5)(c)4.a. a. The general physical and mental condition of the resident, including any unusual symptoms or actions;

DHS 132.45(5)(c)4.b. b. All incidents or accidents including time, place, details of incident or accident, action taken, and follow-up care;

DHS 132.45(5)(c)4.c. c. The administration of all medications (see s. DHS 132.60 (5) (d)), the need for PRN medications and the resident’s response, refusal to take medication, omission of medications, errors in the administration of medications, and drug reactions;

DHS 132.45(5)(c)4.d. d. Food and fluid intake, when the monitoring of intake is necessary;

DHS 132.45(5)(c)4.e. e. Any unusual occurrences of appetite or refusal or reluctance to accept diets;

DHS 132.45(5)(c)4.f. f. Summary of restorative nursing measures which are provided;

DHS 132.45(5)(c)4.g. g. Summary of the use of physical and chemical restraints.

DHS 132.45(5)(c)4.h. h. Other non-routine nursing care given;

DHS 132.45(5)(c)4.i. i. The condition of a resident upon discharge; and

DHS 132.45(5)(c)4.j. j. The time of death, the physician called, and the person to whom the body was released.

DHS 132.45(5)(d) (d) Social service records. Notes regarding pertinent social data and action taken.

DHS 132.45(5)(e) (e) Activities records. Documentation of activities programming, a summary of attendance, and quarterly progress notes.

DHS 132.45(5)(f) (f) Rehabilitative services.

DHS 132.45(5)(f)1. 1. An evaluation of the rehabilitative needs of the resident; and

DHS 132.45(5)(f)2. 2. Progress notes detailing treatment given, evaluation, and progress.

DHS 132.45(5)(h) (h) Dental services. Records of all dental services.

DHS 132.45(5)(i) (i) Diagnostic services. Records of all diagnostic tests performed during the resident’s stay in the facility.

DHS 132.45(5)(j) (j) Plan of care. Plan of care required by s. DHS 132.60 (8).

DHS 132.45(5)(k) (k) Authorization or consent. A photocopy of any court order or other document authorizing another person to speak or act on behalf of the resident and any resident consent form required under this chapter, except that if the authorization or consent form exceeds one page in length an accurate summary may be substituted in the resident record and the complete authorization or consent form shall in this case be maintained as required under sub. (6) (i). The summary shall include:

DHS 132.45(5)(k)1. 1. The name and address of the guardian or other person having authority to speak or act on behalf of the resident;

DHS 132.45(5)(k)2. 2. The date on which the authorization or consent takes effect and the date on which it expires;

DHS 132.45(5)(k)3. 3. The express legal nature of the authorization or consent and any limitations on it; and

DHS 132.45(5)(k)4. 4. Any other factors reasonably necessary to clarify the scope and extent of the authorization or consent.

DHS 132.45(5)(L) (L) Discharge or transfer information. Documents, prepared upon a resident’s discharge or transfer from the facility, summarizing, when appropriate:

DHS 132.45(5)(L)1. 1. Current medical findings and condition;

DHS 132.45(5)(L)2. 2. Final diagnoses;

DHS 132.45(5)(L)3. 3. Rehabilitation potential;

DHS 132.45(5)(L)4. 4. A summary of the course of treatment;

DHS 132.45(5)(L)5. 5. Nursing and dietary information;

DHS 132.45(5)(L)6. 6. Ambulation status;

DHS 132.45(5)(L)7. 7. Administrative and social information; and

DHS 132.45(5)(L)8. 8. Needed continued care and instructions.

DHS 132.45(6) (6) Other records. The facility shall retain:

DHS 132.45(6)(a) (a) Dietary records. All menus and therapeutic diets;

DHS 132.45(6)(b) (b) Staffing records. Records of staff work schedules and time worked;

DHS 132.45(6)(c) (c) Safety tests. Records of tests of fire detection, alarm, and extinguishment equipment;

DHS 132.45(6)(d) (d) Resident census. At least a weekly census of all residents, indicating numbers of residents requiring each level of care;

DHS 132.45(6)(e) (e) Professional consultations. Documentation of professional consultations by:

DHS 132.45(6)(e)1. 1. A dietitian, if required by s. DHS 132.63 (2) (b);

DHS 132.45(6)(e)2. 2. A registered nurse, if required by s. DHS 132.62 (2); and

DHS 132.45(6)(e)3. 3. Others, as may be used by the facility;

DHS 132.45(6)(f) (f) Inservice and orientation programs. Subject matter, instructors and attendance records of all inservice and orientation programs;

DHS 132.45(6)(g) (g) Transfer agreements. Transfer agreements, unless exempt under s. DHS 132.53 (4);