DHS 131.32(2)(d) (d) Ensure that a system is established and maintained to document the disposal of controlled drugs.

DHS 131.32(2)(e) (e) Ensure that the medical needs of the patients are being met.

DHS 131.32(2)(f) (f) Provide liaison as necessary between the core team and the attending physician.

DHS 131.32(2)(g) (g) Ensure that a system is established for the disposal of controlled drugs.

DHS 131.32 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.

DHS 131.33 DHS 131.33 Clinical record.

DHS 131.33(1) (1) General. A hospice shall establish a single and complete clinical record for every patient. Clinical record information shall remain confidential except as required by law or a third-party payment contract.

DHS 131.33(2) (2) Documentation and accessibility. The clinical record shall be completely accurate and up-to-date, readily accessible to all individuals providing services to the patient or the patient’s family, or both, and shall be systematically organized to facilitate prompt retrieval of information.

DHS 131.33(3) (3) Content. A patient’s clinical record shall contain all of the following:

DHS 131.33(3)(a) (a) The initial, integrated and updated plans of care prepared under s. DHS 131.21.

DHS 131.33(3)(b) (b) The initial, comprehensive and updated comprehensive assessments.

DHS 131.33(3)(c) (c) Complete documentation of all services provided to the patient or the patient’s family or both, including:

DHS 131.33(3)(c)1. 1. Assessments.

DHS 131.33(3)(c)2. 2. Interventions.

DHS 131.33(3)(c)3. 3. Instructions given to the patient or family, or both.

DHS 131.33(3)(c)4. 4. Coordination of activities.

DHS 131.33(3)(d) (d) Signed copies of the notice of patient rights under s. DHS 131.19 (1) (a) and service authorization statement under s. DHS 131.17 (4) (b).

DHS 131.33(3)(e) (e) A current medications list.

DHS 131.33(3)(f) (f) Responses to medications, symptom management, treatments, and services.

DHS 131.33(3)(g) (g) Outcome measure data elements, as described in s. DHS 131.20 (5).

DHS 131.33(3)(h) (h) Physician certification and recertification of terminal illness.

DHS 131.33(3)(i) (i) A statement of whether or not the patient, if an adult, has prepared an advance directive; and a copy of the advance directive, if prepared.

DHS 131.33(3)(j) (j) Physician orders.

DHS 131.33(3)(k) (k) Patient and family identification information.

DHS 131.33(3)(L) (L) Referral information, medical history and pertinent hospital discharge summaries.

DHS 131.33(3)(m) (m) Transfer and discharge summaries.

DHS 131.33(4) (4) Authentication.

DHS 131.33(4)(a) (a) Entries. All entries shall be legible, permanently recorded, dated and authenticated by the person making the entry, and shall include that person’s name and title.

DHS 131.33(4)(b) (b) Written record. A written record shall be made for every service provided on the date the service is provided. This written record shall be incorporated into the clinical record no later than 7 calendar days after the date of service.