DHS 133.21(5)(a) (a) Patient identification information.

DHS 133.21(5)(b) (b) Appropriate hospital information (discharge summary, diagnosis, current patient status, post-discharge plan of care).

DHS 133.21(5)(c) (c) Patient evaluation and assessment.

DHS 133.21(5)(d) (d) Plan of care.

DHS 133.21(5)(e) (e) Physician’s, advanced practice nurse prescriber’s, or physician assistant’s orders.

DHS 133.21(5)(f) (f) Medication list and documentation of patient instructions.

DHS 133.21(5)(g) (g) Progress notes, as frequently as necessary to document patient status and services provided.

DHS 133.21(5)(h) (h) Summaries of reviews of the plan of care.

DHS 133.21(5)(i) (i) Discharge summary, completed within 30 days following discharge.

DHS 133.21(6) (6) Form of entries. All entries in the medical record shall be legible, permanently recorded, dated and authenticated with the name and title of the person making the entry.

DHS 133.21(7) (7) Abbreviations. Medical symbols and abbreviations may be used in medical records if approved by a written agency policy which defines the symbols and abbreviations and controls their use.

DHS 133.21 History History: Cr. Register, May, 1984, No. 341, eff. 6-1-84; CR 07-060: am. (5) (d), (e), (h) and (i) Register November 2007 No. 623, eff. 12-1-07; CR 16-077: am. (4), (5) (a) to (h) Register September 2017 No. 741 eff. 10-1-17; correction in (5) (b) made under s. 35.17, Stats., Register September 2017 No. 741.