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)(b)1.1. An admission medical evaluation by a physician or physician extender, including:
DHS 132.45(5)(b)2.
2. All physician's orders including, when applicable, orders concerning:
DHS 132.45(5)(b)5.
5. Alternate visit schedule, and justification for such alternate visits.
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.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.e.
e. Any unusual occurrences of appetite or refusal or reluctance to accept diets;
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)(i)
(i) Diagnostic services. Records of all diagnostic tests performed during the resident's stay in the facility.
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(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)(f)
(f) Inservice and orientation programs. Subject matter, instructors and attendance records of all inservice and orientation programs;
DHS 132.45(6)(h)
(h) Funds and property statement. The statement prepared upon a resident's discharge or transfer from the facility that accounts for all funds and property held by the facility for the resident.
DHS 132.45(6)(i)
(i) Court orders and consent forms. Copies of court orders or other documents, if any, authorizing another person to speak or act on behalf of the resident.
DHS 132.45 History
History: Cr.
Register, July, 1982, No. 319, eff. 8-1-82; am. (1) (3) (c) (5) (intro.), (b) 1. intro. and e., 2. a. and d., 3., (c) 1. and 2., (d) 1., (e), (f) 1. and (g), (6) (g), renum. (4) (a) to (e), (5) (e) and (6) (h) to be (4) (c) to (g), (5) (L) and (6) (i) and am. (5) (L), cr. (4) (a) and (b), (5) (e) and (6) (h),
Register, January, 1987, No. 373, eff. 2-1-87;
CR 04-053: r. and recr. (3) and (5) (d), am. (4) (g) 2. and (5) (e), r. (5) (g)
Register October 2004 No. 586, eff. 11-1-04;
CR 06-053: r. (4) (a), (b) and (d), (e) and (f) 1. and 3., am. (4) (f) 2. (g) 1., (5) (b) 3. and 5., (c) 4. g., and (6) (h), renum. (4) (f) 2., 4. and 5. to be (4) (f) 1., 2. and 3.,
Register August 2007 No. 620, eff. 9-1-07.
DHS 132.46
DHS 132.46 Quality assessment and assurance. DHS 132.46(1)(1)
Committee maintenance and composition. A facility shall maintain a quality assessment and assurance committee for the purpose of identifying and addressing quality of care issues. The committee shall be comprised of at least all of the following individuals:
DHS 132.46(1)(b)
(b) The medical director or a physician designated by the facility.
DHS 132.46(2)
(2)
Committee responsibilities. The quality assessment and assurance committee shall do all of the following:
DHS 132.46(2)(a)
(a) Meet at least quarterly to identify quality of care issues with respect to which quality assessment and assurance activities are necessary.
DHS 132.46(2)(b)
(b) Identify, develop and implement appropriate plans of action to correct identified quality deficiencies.
DHS 132.46(3)
(3)
Confidentiality. The department may not require disclosure of the records of the quality assessment and assurance committee except to determine compliance with the requirements of this section. This paragraph does not apply to any record otherwise specified in this chapter or s.
50.04 (3),
50.07 (1) (c) or
146.82 (2) (a) 5., Stats.
DHS 132.46 History
History: CR 04-053: cr.
Register October 2004 No. 586, eff. 11-1-04.
