DHS 132.45(4)(g)3. 3. Symbols and abbreviations may be used in medical records if approved by a written facility policy which defines the symbols and abbreviations and which controls their use.

DHS 132.45(5) (5) Medical records — content. Except for persons admitted for short-term care, to whom s. DHS 132.70 (7) applies, each resident’s medical record shall contain:

DHS 132.45(5)(a) (a) Identification and summary sheet.

DHS 132.45(5)(b) (b) Physician’s documentation.

DHS 132.45(5)(b)1. 1. An admission medical evaluation by a physician or physician extender, including:

DHS 132.45(5)(b)1.a. a. A summary of prior treatment;

DHS 132.45(5)(b)1.b. b. Current medical findings;

DHS 132.45(5)(b)1.c. c. Diagnoses at the time of admission to the facility;

DHS 132.45(5)(b)1.d. d. The resident’s rehabilitation potential;

DHS 132.45(5)(b)1.e. e. The results of the physical examination required by s. DHS 132.52 (3); and

DHS 132.45(5)(b)1.f. f. Level of care;

DHS 132.45(5)(b)2. 2. All physician’s orders including, when applicable, orders concerning:

DHS 132.45(5)(b)2.a. a. Admission to the facility as required by s. DHS 132.52 (2) (a);

DHS 132.45(5)(b)2.b. b. Medications and treatments as specified by s. DHS 132.60 (5);

DHS 132.45(5)(b)2.c. c. Diets as required by s. DHS 132.63 (4);

DHS 132.45(5)(b)2.d. d. Rehabilitative services as required by s. DHS 132.64 (2);

DHS 132.45(5)(b)2.e. e. Limitations on activities;

DHS 132.45(5)(b)2.f. f. Restraint orders as required by s. DHS 132.60 (6); and

DHS 132.45(5)(b)2.g. g. Discharge or transfer as required by s. DHS 132.53;

DHS 132.45(5)(b)3. 3. Physician progress notes following each visit.

DHS 132.45(5)(b)4. 4. Annual physical examination, if required; and

DHS 132.45(5)(b)5. 5. Alternate visit schedule, and justification for such alternate visits.

DHS 132.45(5)(c) (c) Nursing service documentation.

DHS 132.45(5)(c)1. 1. A history and assessment of the resident’s nursing needs as required by s. DHS 132.52;

DHS 132.45(5)(c)2. 2. Initial care plan as required by s. DHS 132.52 (4), and the care plan required by s. DHS 132.60 (8);

DHS 132.45(5)(c)3. 3. Nursing notes are required as follows:

DHS 132.45(5)(c)3.a. a. For residents requiring skilled care, a narrative nursing note shall be required as often as needed to document the resident’s condition, but at least weekly; and

DHS 132.45(5)(c)3.b. b. For residents not requiring skilled care, a narrative nursing note shall be required as often as needed to document the resident’s condition, but at least every other week;

DHS 132.45(5)(c)4. 4. In addition to subds. 1., 2., and 3., nursing documentation describing: