DHS 83.42(1)(c) (c) Medical, social, and, if any, psychiatric history.

DHS 83.42(1)(d) (d) Current personal physician, if any.

DHS 83.42(1)(e) (e) Results of the initial health screening under s. DHS 83.28 (4) and subsequent health examinations under s. DHS 83.38 (1) (g).

DHS 83.42(1)(f) (f) Admission agreement.

DHS 83.42(1)(g) (g) Documentation of significant incidents and illnesses, including the dates, times and circumstances.

DHS 83.42(1)(h) (h) Assessments completed as required under s. DHS 83.35 (1).

DHS 83.42(1)(i) (i) Individual service plan and resident satisfaction evaluation.

DHS 83.42(1)(j) (j) Documentation to accurately describe the resident’s condition, significant changes in condition, changes in treatment and response to treatment.

DHS 83.42(1)(k) (k) Results of the annual resident evacuation evaluation.

DHS 83.42(1)(L) (L) Documentation of sensory impairment of the resident as required under s. DHS 83.48 (7) (b).

DHS 83.42(1)(m) (m) Summary of discharge information as required under s. DHS 83.31 (7).

DHS 83.42(1)(n) (n) Any department-approved resident-specific waiver, variance or approval.

DHS 83.42(1)(o) (o) Physician’s orders or other authorized practitioner’s written orders for nursing care, medications, rehabilitation services and therapeutic diets.

DHS 83.42(1)(p) (p) Current list of the type and dosage of medications or supplements.

DHS 83.42(1)(q) (q) Results of the quarterly psychotropic medication assessments as required in s. DHS 83.37 (1) (h) 1.

DHS 83.42(1)(r) (r) Documentation of administration of all medications, supplements, the person administering the medications or supplements, any side effects observed by the employee or symptoms reported by the resident, the need for PRN medications and the resident’s response, refusal to take medication, omissions of medications, errors in the administration of medications and drug reactions.

DHS 83.42(1)(s) (s) Photocopy of any court order or other document authorizing another person to speak or act on behalf of the resident, or other legal documents as required which affect the care and treatment of a resident.

DHS 83.42(1)(t) (t) Documentation of all other services including rehabilitation services, treatments and therapeutic diets.

DHS 83.42(1)(u) (u) Completed notice of pre-admission assessment requirement under s. DHS 83.30.

DHS 83.42(1)(v) (v) Nursing care procedures and the amount of time spent each week by a registered nurse or licensed practical nurse in performing the nursing care procedures. Only time actually spent by the nurse with the resident may be included in the calculation of nursing care time.

DHS 83.42(1)(w) (w) Plans of care for terminally ill residents.

DHS 83.42(1)(x) (x) Date, time and circumstances of the resident’s death, including the name of the person to whom the body is released.

DHS 83.42(2) (2) The licensee shall ensure all resident records are adequately safeguarded against destruction, loss or unauthorized access or use.

DHS 83.42(3) (3) The employee in charge on each work shift shall have a means to access resident records.

DHS 83.42 History History: CR 07-095: cr. Register January 2009 No. 637, eff. 4-1-09.

subch. VIII of ch. DHS 83 Subchapter VIII — Physical Environment

DHS 83.43 DHS 83.43 Furnishings and equipment.

DHS 83.43(1) (1) Environment. The CBRF shall provide a living environment that is safe, clean, comfortable, and homelike. All common dining and living areas shall contain furnishings appropriate to the intended use of the room.

DHS 83.43(2) (2) Bedroom furnishings. If a resident does not provide the resident’s own bedroom furnishings, the CBRF shall provide all of the following: