DHS 133.19(1)(f)
(f) Procedures for submitting clinical and progress notes, scheduling visits, and undertaking periodic patient evaluation.
DHS 133.19(2)
(2) Qualifications of contractors. All providers of services under contract shall meet the same qualifications required of practitioners of the same service under the terms of this chapter.
DHS 133.19 History
History: Cr.
Register, May, 1984, No. 341, eff. 6-1-84.
DHS 133.20(1)
(1)
Requirement. A plan of care, including physician's, advanced practice nurse prescriber's, or physician assistant's orders, shall be established for every patient accepted for care and shall be incorporated in the patient's medical record. An initial plan shall be developed within 72 hours of acceptance. The total plan of care shall be developed in consultation with the patient, home health agency staff, contractual providers, and the patient's physician, advanced practice nurse prescriber, or physician assistant and shall be signed and dated by the physician, advanced practice nurse prescriber, or physician assistant within 20 working days following the patient's admission for care.
DHS 133.20(2)
(2) Contents of plan. Each plan developed under
sub. (1) shall include:
DHS 133.20(2)(a)
(a) Measurable time-specific goals, with benchmark dates for review; and
DHS 133.20(2)(b)
(b) The methods for delivering needed care, and an indication of which professional disciplines are responsible for delivering the care.
DHS 133.20(3)
(3) Review of plan. The total plan of care shall be reviewed by the attending physician, advanced practice nurse prescriber, or physician assistant, and appropriate agency personnel as often as required by the patient's condition, but no less often than every 60 days. The agency shall promptly notify the physician, the advanced practice nurse prescriber, or the physician assistant of any changes in the patient's condition that suggest a need to modify the plan of care.
DHS 133.20(4)
(4) Orders. Drugs and treatment shall be administered by the agency staff only as ordered by the attending physician, advanced practice nurse prescriber, or physician assistant. The nurse or therapist shall immediately record and sign and date oral orders and obtain the physician's, the advanced practice nurse prescriber's or physician assistant's countersignature and date within 20 working days.
DHS 133.20 History
History: Cr.
Register, May, 1984, No. 341, eff. 6-1-84; am. (4),
Register, April, 2001, No. 544, eff. 5-1-01;
CR 07-060: am. (1), (3) and (4)
Register November 2007 No. 623, eff. 12-1-07;
CR 16-077: am. (1), (3), (4) Register September 2017 No. 741 eff. 10-1-17.
DHS 133.21(1)
(1)
Requirement. A medical record shall be maintained on each patient and shall be completely and accurately documented, systematically organized and readily accessible to authorized personnel.
DHS 133.21(2)
(2) Security. Medical record information shall be safeguarded against loss, destruction or unauthorized use. Written procedures shall be established to control use and removal of records and to identify conditions for release of information.
DHS 133.21 Note
Note: For information regarding confidentiality of patient health care records, see s.
146.82, Stats.
DHS 133.21(3)
(3) Retention. For the purposes of this chapter medical records shall be retained for a minimum of 5 years following discharge. Arrangements shall be made for the storage and safekeeping of records if the agency goes out of business.
DHS 133.21(4)
(4) Transfer. If a patient is transferred to another health facility or agency, a copy of the record or summary of the record shall be provided to the receiving agency or facility.
DHS 133.21(5)
(5) Content. The medical record shall document the patient's condition, problems, progress and services rendered, and shall include:
DHS 133.21(5)(b)
(b) Appropriate hospital information (discharge summary, diagnosis, current patient status, post-discharge plan of care).
DHS 133.21(5)(e)
(e) Physician's, advanced practice nurse prescriber's, or physician assistant's orders.
DHS 133.21(5)(g)
(g) Progress notes, as frequently as necessary to document patient status and services provided.
DHS 133.21(5)(i)
(i) Discharge summary, completed within 30 days following discharge.
DHS 133.21(6)
(6) Form of entries. All entries in the medical record shall be legible, permanently recorded, dated and authenticated with the name and title of the person making the entry.
DHS 133.21(7)
(7) Abbreviations. Medical symbols and abbreviations may be used in medical records if approved by a written agency policy which defines the symbols and abbreviations and controls their use.
DHS 133.21 History
History: Cr.
Register, May, 1984, No. 341, eff. 6-1-84;
CR 07-060: am. (5) (d), (e), (h) and (i)
Register November 2007 No. 623, eff. 12-1-07;
CR 16-077: am. (4), (5) (a) to (h) Register September 2017 No. 741 eff. 10-1-17; correction in (5) (b) made under s. 35.17, Stats., Register September 2017 No. 741.
