DHS 134.47(3)(h)1.1. All entries in records shall be legible, permanently recorded, dated and authenticated with the name and title of the person making the entry. A rubber stamp reproduction or electronic representation of a person's signature may be used instead of a handwritten signature if:
DHS 134.47(3)(h)1.a.
a. The stamp or electronic representation is used only by the person who makes the entry; and
DHS 134.47(3)(h)1.b.
b. The facility possesses a statement signed by the person, certifying that only that person shall possess and use the stamp or electronic representation.
DHS 134.47(3)(h)2.
2. Symbols and abbreviations may be used in resident records if approved by a written facility policy which defines the symbols and abbreviations and controls their use.
DHS 134.47(4)
(4)
Contents of a resident's record. Except for a person admitted for short-term care, to whom s.
DHS 134.70 (7) applies, a resident's record shall contain all information relevant to admission and to the resident's care and treatment, including the following:
DHS 134.47(4)(a)
(a) Admission information. Information obtained on admission, including:
DHS 134.47(4)(a)1.
1. Name, date of admission, birth date and place, citizenship status, marital status and social security number;
DHS 134.47(4)(a)2.
2. Father's name and birthplace and mother's maiden name and birthplace;
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)9.
9. Sources of support, including social security, veterans' benefits and insurance;
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)(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)(f)
(f) Nursing service documentation. Documentation of nursing needs and the nursing services provided, including:
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.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.g.
g. Any unusual occurrences of appetite or refusal or reluctance to accept diets;
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)(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)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)(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;
