DHS 134.47(4)(a)3. 3. Names and addresses of parents, legal guardian and next of kin;
DHS 134.47(4)(a)4. 4. Sex, race, height, weight, color of hair, color of eyes, identifying marks and recent photograph;
DHS 134.47(4)(a)5. 5. Reason for admission or referral;
DHS 134.47(4)(a)6. 6. Type and legal status of admission;
DHS 134.47(4)(a)7. 7. Legal competency status;
DHS 134.47(4)(a)8. 8. Language spoken or understood;
DHS 134.47(4)(a)9. 9. Sources of support, including social security, veterans' benefits and insurance;
DHS 134.47(4)(a)10. 10. Religious affiliation, if any;
DHS 134.47(4)(a)11. 11. 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); and
DHS 134.47(4)(a)12. 12. Any physician's concurrence under s. DHS 134.52 (2) (c) concerning admission to the facility.
DHS 134.47(4)(b) (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.
DHS 134.47(4)(c) (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) and (b). The summary shall include:
DHS 134.47(4)(c)1. 1. The name and address of the guardian or other person having authority to speak or act on behalf of the resident;
DHS 134.47(4)(c)2. 2. The date on which the authorization or consent takes effect and the date on which it expires;
DHS 134.47(4)(c)3. 3. The express legal nature of the authorization or consent and any limitations on it; and
DHS 134.47(4)(c)4. 4. Any other facts that are reasonably necessary to clarify the scope and extent of the authorization or consent.
DHS 134.47(4)(d) (d) Resident care planning documentation. Resident care planning documentation, including:
DHS 134.47(4)(d)1. 1. The comprehensive evaluation of the resident and written training and habilitation objectives;
DHS 134.47(4)(d)2. 2. The annual review of the resident's program by the interdisciplinary team;
DHS 134.47(4)(d)3. 3. 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;
DHS 134.47(4)(d)4. 4. Professional and special programs and service plans, evaluations and progress notes; and
DHS 134.47(4)(d)5. 5. Direct care staff notes reflecting the projected and actual outcome of the resident's habilitation or rehabilitation program.
DHS 134.47(4)(e) (e) Medical service documentation. Documentation of medical services and treatments provided to the resident, including:
DHS 134.47(4)(e)1. 1. Physician orders for:
DHS 134.47(4)(e)1.a. a. Medications and treatments;
DHS 134.47(4)(e)1.c. c. Special or professional services; and
DHS 134.47(4)(e)1.d. d. Limitations on activities;
DHS 134.47(4)(e)2. 2. Restraint orders required under s. DHS 134.60 (5) (b);
DHS 134.47(4)(e)3. 3. Discharge or transfer records required under s. DHS 134.53 (4) (d);
DHS 134.47(4)(e)4. 4. Physician progress notes following each physician visit required under s. DHS 134.66 (2) (b) 4.; and
DHS 134.47(4)(e)5. 5. The report on the resident's annual physical examination.
DHS 134.47(4)(f) (f) Nursing service documentation. Documentation of nursing needs and the nursing services provided, including:
DHS 134.47(4)(f)1. 1. The nursing care component of the individual program plan reviewed and revised annually as required by s. DHS 134.60 (1) (c) 2;
DHS 134.47(4)(f)2. 2. Nursing notes as needed to document the resident's condition:
DHS 134.47(4)(f)3. 3. Other nursing documentation describing;
DHS 134.47(4)(f)3.a. a. The general physical and mental condition of the resident, including any unusual symptoms or behavior;
DHS 134.47(4)(f)3.b. b. All incidents or accidents, including time, place, details of the incident or accident, action taken and follow-up care;
DHS 134.47(4)(f)3.c. c. Functional training and habilitation;
DHS 134.47(4)(f)3.d. d. 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;
DHS 134.47(4)(f)3.e. e. Height and weight;
DHS 134.47(4)(f)3.f. f. Food and fluid intake, when the monitoring of intake is necessary;
DHS 134.47(4)(f)3.g. g. Any unusual occurrences of appetite or refusal or reluctance to accept diets;
DHS 134.47(4)(f)3.h. h. Rehabilitative nursing measures provided;
DHS 134.47(4)(f)3.i. i. The use of restraints, documentation for which is required under s. DHS 134.60 (5) (b) 8.;
DHS 134.47(4)(f)3.j. j. Immunizations and other non-routine nursing care given;
DHS 134.47(4)(f)3.k. k. Any family visits and contacts;
DHS 134.47(4)(f)3.L. L. The condition of a resident upon discharge; and
DHS 134.47(4)(f)3.m. m. The time of death, the physician called and the person to whom the body was released.
DHS 134.47(4)(g) (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.
DHS 134.47(4)(h) (h) Special and professional services documentation. Progress notes documenting consultations and services provided by:
DHS 134.47(4)(h)1. 1. Psychologists;
DHS 134.47(4)(h)2. 2. Speech pathologists and audiologists; and
DHS 134.47(4)(h)3. 3. Occupational and physical therapists.
DHS 134.47(4)(i) (i) Dental records. Dental records, as follows:
DHS 134.47(4)(i)1. 1. A permanent dental record for each resident;
DHS 134.47(4)(i)2. 2. Documentation of an oral examination at the time of admission or prior to admission which satisfies the requirements under s. DHS 134.65 (2) (a); and
DHS 134.47(4)(i)3. 3. Dental summary progress reports recorded as needed.
DHS 134.47(4)(j) (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.
DHS 134.47(4)(k) (k) Discharge or transfer information. Documents prepared when a resident is discharged or transferred from the facility, including:
DHS 134.47(4)(k)1. 1. A summary of habilitative, rehabilitative, medical, emotional, social and cognitive findings and progress;
DHS 134.47(4)(k)2. 2. A summary and current status report on special and professional treatment services;
DHS 134.47(4)(k)3. 3. A summary of need for continued care and of plans for care;
DHS 134.47(4)(k)4. 4. Nursing and nutritional information;
DHS 134.47(4)(k)5. 5. Administrative and social information;
DHS 134.47(4)(k)6. 6. An up-to-date statement of the resident's account as required by s. DHS 134.31 (3) (c) 3.; and
DHS 134.47(4)(k)7. 7. In the case of a transfer, written documentation of the reason for the transfer.
DHS 134.47(4)(L) (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.
DHS 134.47(5) (5)Record retention.
DHS 134.47(5)(a) (a) The facility shall retain resident records as required under sub. (3) (g).
DHS 134.47(5)(b) (b) The facility shall maintain the following documents on file within the facility for at least 5 years after a resident's discharge or death:
DHS 134.47(5)(b)1. 1. Copies of any court orders or other documents authorizing another person to speak or act on behalf of the resident; and
DHS 134.47(5)(b)2. 2. 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).
DHS 134.47(5)(c) (c) The facility shall retain all records not directly related to resident care for at least 2 years. These shall include:
DHS 134.47(5)(c)1. 1. 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;
DHS 134.47(5)(c)2. 2. All menus and records of modified diets, including the average portion size of items;
DHS 134.47(5)(c)3. 3. 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);
DHS 134.47(5)(c)4. 4. 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;
DHS 134.47(5)(c)5. 5. 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;
DHS 134.47(5)(c)6. 6. 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;
DHS 134.47(5)(c)7. 7. Medical transfer service agreements and agreements with outside agency service providers; and
DHS 134.47(5)(c)8. 8. 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 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.
subch. IV of ch. DHS 134 Subchapter IV — Admission, Retention and Removal
DHS 134.51 DHS 134.51Limitations on admissions and retentions.
DHS 134.51(1)(1)Limitations on admission.
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.
DHS 134.51(1)(b) (b) Persons requiring unavailable services.
Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.