Chapter DHS 134

DHS 134.47(3)(g)3.b. b. The facility permanently retains at least a record of the resident’s identity, final diagnosis, physician and dates of admission and discharge.

DHS 134.47(3)(g)4. 4. In the event that a facility closes, the facility shall arrange for the storage and safekeeping of resident records for the period and under the conditions required by this paragraph.

DHS 134.47(3)(g)5. 5. If the ownership of a facility changes, the resident records and indexes shall remain with the facility.

DHS 134.47 Note Note: Although this chapter obliges a facility to retain a resident’s record for only 5 years following the resident’s discharge or death, ch. DHS 92 requires a facility to retain the record of an individual with developmental disabilities for at least 7 years. See s. DHS 92.12 (1).

DHS 134.47(3)(h) (h) Preparation.

DHS 134.47(3)(h)1. 1. All entries in records shall be legible, permanently recorded, dated and authenticated with the name and title of the person making the entry. A rubber stamp reproduction or electronic representation of a person’s signature may be used instead of a handwritten signature if:

DHS 134.47(3)(h)1.a. a. The stamp or electronic representation is used only by the person who makes the entry; and

DHS 134.47(3)(h)1.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 134.47(3)(h)2. 2. Symbols and abbreviations may be used in resident records if approved by a written facility policy which defines the symbols and abbreviations and controls their use.

DHS 134.47(4) (4) Contents of a resident’s record. Except for a person admitted for short-term care, to whom s. DHS 134.70 (7) applies, a resident’s record shall contain all information relevant to admission and to the resident’s care and treatment, including the following:

DHS 134.47(4)(a) (a) Admission information. Information obtained on admission, including:

DHS 134.47(4)(a)1. 1. Name, date of admission, birth date and place, citizenship status, marital status and social security number;

DHS 134.47(4)(a)2. 2. Father’s name and birthplace and mother’s maiden name and birthplace;

DHS 134.47(4)(a)3. 3. Names and addresses of parents, legal guardian and next of kin;

DHS 134.47(4)(a)4. 4. Sex, race, height, weight, color of hair, color of eyes, identifying marks and recent photograph;

DHS 134.47(4)(a)5. 5. Reason for admission or referral;

DHS 134.47(4)(a)6. 6. Type and legal status of admission;

DHS 134.47(4)(a)7. 7. Legal competency status;

DHS 134.47(4)(a)8. 8. Language spoken or understood;

DHS 134.47(4)(a)9. 9. Sources of support, including social security, veterans’ benefits and insurance;

DHS 134.47(4)(a)10. 10. Religious affiliation, if any;

DHS 134.47(4)(a)11. 11. Medical evaluation results, including current medical findings, a summary of prior treatment, the diagnosis at time of admission, the resident’s habilitative or rehabilitative potential and level of care and results of the physical examination required under s. DHS 134.52 (4); and

DHS 134.47(4)(a)12. 12. Any physician’s concurrence under s. DHS 134.52 (2) (c) concerning admission to the facility.

DHS 134.47(4)(b) (b) Preadmission evaluation reports. Any report or summary of an evaluation conducted by the interdisciplinary team or a team member under s. DHS 134.52 (3) prior to an individual’s admission to the facility and reports of any other relevant medical histories or evaluations conducted prior to the individual’s admission.

DHS 134.47(4)(c) (c) Authorizations or consents. 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 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. (5) (a) and (b). The summary shall include:

DHS 134.47(4)(c)1. 1. The name and address of the guardian or other person having authority to speak or act on behalf of the resident;

DHS 134.47(4)(c)2. 2. The date on which the authorization or consent takes effect and the date on which it expires;

DHS 134.47(4)(c)3. 3. The express legal nature of the authorization or consent and any limitations on it; and

DHS 134.47(4)(c)4. 4. Any other facts that are reasonably necessary to clarify the scope and extent of the authorization or consent.

DHS 134.47(4)(d) (d) Resident care planning documentation. Resident care planning documentation, including:

DHS 134.47(4)(d)1. 1. The comprehensive evaluation of the resident and written training and habilitation objectives;

DHS 134.47(4)(d)2. 2. The annual review of the resident’s program by the interdisciplinary team;

DHS 134.47(4)(d)3. 3. In measurable terms, documentation by the qualified intellectual disabilities professional of the resident’s performance in relationship to the objectives contained in the individual program plan;

DHS 134.47(4)(d)4. 4. Professional and special programs and service plans, evaluations and progress notes; and

DHS 134.47(4)(d)5. 5. Direct care staff notes reflecting the projected and actual outcome of the resident’s habilitation or rehabilitation program.

DHS 134.47(4)(e) (e) Medical service documentation. Documentation of medical services and treatments provided to the resident, including:

DHS 134.47(4)(e)1. 1. Physician orders for:

DHS 134.47(4)(e)1.a. a. Medications and treatments;

DHS 134.47(4)(e)1.b. b. Diets;

DHS 134.47(4)(e)1.c. c. Special or professional services; and

DHS 134.47(4)(e)1.d. d. Limitations on activities;

DHS 134.47(4)(e)2. 2. Restraint orders required under s. DHS 134.60 (5) (b);

DHS 134.47(4)(e)3. 3. Discharge or transfer records required under s. DHS 134.53 (4) (d);

DHS 134.47(4)(e)4. 4. Physician progress notes following each physician visit required under s. DHS 134.66 (2) (b) 4.; and

DHS 134.47(4)(e)5. 5. The report on the resident’s annual physical examination.

DHS 134.47(4)(f) (f) Nursing service documentation. Documentation of nursing needs and the nursing services provided, including:

DHS 134.47(4)(f)1. 1. The nursing care component of the individual program plan reviewed and revised annually as required by s. DHS 134.60 (1) (c) 2;

DHS 134.47(4)(f)2. 2. Nursing notes as needed to document the resident’s condition:

DHS 134.47(4)(f)3. 3. Other nursing documentation describing;

DHS 134.47(4)(f)3.a. a. The general physical and mental condition of the resident, including any unusual symptoms or behavior;

DHS 134.47(4)(f)3.b. b. All incidents or accidents, including time, place, details of the incident or accident, action taken and follow-up care;

DHS 134.47(4)(f)3.c. c. Functional training and habilitation;

DHS 134.47(4)(f)3.d. d. The administration of all medications as required under s. DHS 134.60 (4) (d), the need for as-needed administration of medications and the effect that the medication has on the resident’s condition, the resident’s refusal to take medication, omission of medications, errors in the administration of medications and drug reactions;

DHS 134.47(4)(f)3.e. e. Height and weight;

DHS 134.47(4)(f)3.f. f. Food and fluid intake, when the monitoring of intake is necessary;

DHS 134.47(4)(f)3.g. g. Any unusual occurrences of appetite or refusal or reluctance to accept diets;

DHS 134.47(4)(f)3.h. h. Rehabilitative nursing measures provided;

DHS 134.47(4)(f)3.i. i. The use of restraints, documentation for which is required under s. DHS 134.60 (5) (b) 8.;

DHS 134.47(4)(f)3.j. j. Immunizations and other non-routine nursing care given;

DHS 134.47(4)(f)3.k. k. Any family visits and contacts;

DHS 134.47(4)(f)3.L. L. The condition of a resident upon discharge; and

DHS 134.47(4)(f)3.m. m. The time of death, the physician called and the person to whom the body was released.

DHS 134.47(4)(g) (g) Social service documentation. Social service records and any notes regarding pertinent social data and action taken to meet the social service needs of residents.

DHS 134.47(4)(h) (h) Special and professional services documentation. Progress notes documenting consultations and services provided by:

DHS 134.47(4)(h)1. 1. Psychologists;

DHS 134.47(4)(h)2. 2. Speech pathologists and audiologists; and

DHS 134.47(4)(h)3. 3. Occupational and physical therapists.

DHS 134.47(4)(i) (i) Dental records. Dental records, as follows:

DHS 134.47(4)(i)1. 1. A permanent dental record for each resident;

DHS 134.47(4)(i)2. 2. Documentation of an oral examination at the time of admission or prior to admission which satisfies the requirements under s. DHS 134.65 (2) (a); and

DHS 134.47(4)(i)3. 3. Dental summary progress reports recorded as needed.

DHS 134.47(4)(j) (j) Nutritional assessment. The nutritional assessment of the resident, the nutritional component of the resident’s individual program plan and records of diet modifications as required by s. DHS 134.64 (4) (b) 1.

DHS 134.47(4)(k) (k) Discharge or transfer information. Documents prepared when a resident is discharged or transferred from the facility, including:

DHS 134.47(4)(k)1. 1. A summary of habilitative, rehabilitative, medical, emotional, social and cognitive findings and progress;

DHS 134.47(4)(k)2. 2. A summary and current status report on special and professional treatment services;

DHS 134.47(4)(k)3. 3. A summary of need for continued care and of plans for care;

DHS 134.47(4)(k)4. 4. Nursing and nutritional information;

DHS 134.47(4)(k)5. 5. Administrative and social information;

DHS 134.47(4)(k)6. 6. An up-to-date statement of the resident’s account as required by s. DHS 134.31 (3) (c) 3.; and

DHS 134.47(4)(k)7. 7. In the case of a transfer, written documentation of the reason for the transfer.

DHS 134.47(4)(L) (L) Laboratory, radiologic and blood services documentation. A record of any laboratory, radiologic, blood or other diagnostic service obtained or provided under s. DHS 134.68.

DHS 134.47(5) (5) Record retention.

DHS 134.47(5)(a) (a) The facility shall retain resident records as required under sub. (3) (g).

DHS 134.47(5)(b) (b) The facility shall maintain the following documents on file within the facility for at least 5 years after a resident’s discharge or death:

DHS 134.47(5)(b)1. 1. Copies of any court orders or other documents authorizing another person to speak or act on behalf of the resident; and

DHS 134.47(5)(b)2. 2. The original copy of any resident consent document required under this chapter.

DHS 134.47 Note Note: Copies or summaries of the above court orders or other documents and consent documents must be included in the resident’s record. See sub. (4) (c).

DHS 134.47(5)(c) (c) The facility shall retain all records not directly related to resident care for at least 2 years. These shall include:

DHS 134.47(5)(c)1. 1. A separate record for each employee kept current and containing sufficient information to support assignment to the employee’s position and duties, and records of staff work schedules and time worked;