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;