DHS 134.47(3)(c)(c) Index. A master alphabetical resident record index shall be maintained at a central location.
DHS 134.47(3)(d)(d) Confidentiality. The facility shall ensure that all information contained in resident records is kept confidential pursuant to s. 51.30, Stats., and ch. DHS 92, and shall protect the information against loss, destruction or unauthorized use. In this connection:
DHS 134.47(3)(d)1.1. The facility shall have written policies to govern access to and duplication and release of information from resident records; and
DHS 134.47(3)(d)2.2. The facility shall obtain the written consent of the resident or guardian before releasing information to unauthorized individuals.
DHS 134.47(3)(e)(e) Availability of records. Resident records of current residents shall be stored in the facility and shall be easily accessible at all times to persons authorized to provide care and treatment. Resident records of both current and past residents shall be readily available to persons designated by statute or authorized by the resident to obtain the release of the medical records.
DHS 134.47(3)(f)(f) Maintenance.
DHS 134.47(3)(f)1.1. A resident record shall be adequate for planning and evaluation of the resident’s habilitation or rehabilitation program, or both, and shall furnish documentary evidence of the resident’s progress in the program.
DHS 134.47(3)(f)2.2. The facility shall provide adequate space, equipment and supplies to review, index, file and retrieve resident records.
DHS 134.47(3)(g)(g) Retention and destruction.
DHS 134.47(3)(g)1.1. The resident record shall be completed and stored within 60 days following a resident’s discharge or death.
DHS 134.47(3)(g)2.2. For purposes of this chapter, a resident record, including a legible copy of any court order or other document authorizing another person to speak or act on behalf of the resident, shall be retained for a period of at least 5 years following a resident’s discharge or death.
DHS 134.47(3)(g)3.3. A resident’s record may be destroyed after 5 years has elapsed following the resident’s discharge or death, provided that:
DHS 134.47(3)(g)3.a.a. The confidentiality of the information is maintained; and
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 NoteNote: 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;