Sex, race, height, weight, color of hair, color of eyes, identifying marks and recent photograph;
Sources of support, including social security, veterans' benefits and insurance;
Medical evaluation results, including current medical findings, a summary of prior treatment, the diagnosis at time of admission, the resident's habilitative or rehabilitative potential and level of care and results of the physical examination required under s. DHS 134.52 (4)
(b) Preadmission evaluation reports.
Any report or summary of an evaluation conducted by the interdisciplinary team or a team member under s. DHS 134.52 (3)
prior to an individual's admission to the facility and reports of any other relevant medical histories or evaluations conducted prior to the individual's admission.
(c) Authorizations or consents.
A photocopy of any court order or other document authorizing another person to speak or act on behalf of the resident, and any resident consent form required under this chapter, except that if the authorization or consent exceeds one page in length an accurate summary may be substituted in the resident record and the complete authorization or consent form shall in this case be maintained as required under sub. (5) (a)
. The summary shall include:
The name and address of the guardian or other person having authority to speak or act on behalf of the resident;
The date on which the authorization or consent takes effect and the date on which it expires;
The express legal nature of the authorization or consent and any limitations on it; and
Any other facts that are reasonably necessary to clarify the scope and extent of the authorization or consent.
(d) Resident care planning documentation.
Resident care planning documentation, including:
The comprehensive evaluation of the resident and written training and habilitation objectives;
The annual review of the resident's program by the interdisciplinary team;
In measurable terms, documentation by the qualified intellectual disabilities professional of the resident's performance in relationship to the objectives contained in the individual program plan;
Professional and special programs and service plans, evaluations and progress notes; and
Direct care staff notes reflecting the projected and actual outcome of the resident's habilitation or rehabilitation program.
(e) Medical service documentation.
Documentation of medical services and treatments provided to the resident, including:
(f) Nursing service documentation.
Documentation of nursing needs and the nursing services provided, including:
The general physical and mental condition of the resident, including any unusual symptoms or behavior;
All incidents or accidents, including time, place, details of the incident or accident, action taken and follow-up care;
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;
Any unusual occurrences of appetite or refusal or reluctance to accept diets;
The time of death, the physician called and the person to whom the body was released.
(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.
(h) Special and professional services documentation.
Progress notes documenting consultations and services provided by:
(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.
(k) Discharge or transfer information.
Documents prepared when a resident is discharged or transferred from the facility, including:
A summary of habilitative, rehabilitative, medical, emotional, social and cognitive findings and progress;
A summary and current status report on special and professional treatment services;
In the case of a transfer, written documentation of the reason for the transfer.
(L) Laboratory, radiologic and blood services documentation.
A record of any laboratory, radiologic, blood or other diagnostic service obtained or provided under s. DHS 134.68
The facility shall maintain the following documents on file within the facility for at least 5 years after a resident's discharge or death:
Copies of any court orders or other documents authorizing another person to speak or act on behalf of the resident; and
The original copy of any resident consent document required under this chapter.
DHS 134.47 Note
Note: Copies or summaries of the above court orders or other documents and consent documents must be included in the resident's record. See sub. (4) (c).
The facility shall retain all records not directly related to resident care for at least 2 years. These shall include:
A separate record for each employee kept current and containing sufficient information to support assignment to the employee's position and duties, and records of staff work schedules and time worked;
All menus and records of modified diets, including the average portion size of items;
A financial record for each resident which shows all funds held by the facility and all receipts, deposits and disbursements made by the facility as required by s. DHS 134.31 (3) (c)
Any records that document compliance with applicable sanitation, health and environmental safety rules and local ordinances, and written reports of inspections and actions taken to enforce these rules and local ordinances;
Records of inspections by local fire inspectors or departments, records of fire and disaster evacuation drills and records of tests of fire detection, alarm and extinguishing equipment;
Documentation of professional consultation by registered dietitians, registered nurses, social workers and special professional services providers, and other persons used by the facility as consultants;
Medical transfer service agreements and agreements with outside agency service providers; and
A description of subject matter, a summary of contents and a list of instructors and attendance records for all employee orientation and inservice programs.
DHS 134.47 History
Cr. Register, June, 1988, No. 390
, eff. 7-1-88; correction in (3) (d) made under s. 13.93 (2m) (b) 7., Stats., Register, April, 2000, No. 532
; CR 04-053
: am. (3) (h) 1. Register October 2004 No. 586
, eff. 11-1-04; correction in (3) (d) made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637
; 2019 Wis. Act 1: am. (4) (d) 3. Register May 2019 No. 761, eff. 6-1-19
DHS 134.51 Limitations on admissions and retentions. DHS 134.51(1)(a)
(a) Bed capacity.
No facility may admit or retain more persons than the maximum bed capacity for which it is licensed.