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;