DHS 132.45(5)(f)1. 1. An evaluation of the rehabilitative needs of the resident; and

DHS 132.45(5)(f)2. 2. Progress notes detailing treatment given, evaluation, and progress.

DHS 132.45(5)(h) (h) Dental services. Records of all dental services.

DHS 132.45(5)(i) (i) Diagnostic services. Records of all diagnostic tests performed during the resident’s stay in the facility.

DHS 132.45(5)(j) (j) Plan of care. Plan of care required by s. DHS 132.60 (8).

DHS 132.45(5)(k) (k) Authorization or consent. 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 form 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. (6) (i). The summary shall include:

DHS 132.45(5)(k)1. 1. The name and address of the guardian or other person having authority to speak or act on behalf of the resident;

DHS 132.45(5)(k)2. 2. The date on which the authorization or consent takes effect and the date on which it expires;

DHS 132.45(5)(k)3. 3. The express legal nature of the authorization or consent and any limitations on it; and

DHS 132.45(5)(k)4. 4. Any other factors reasonably necessary to clarify the scope and extent of the authorization or consent.

DHS 132.45(5)(L) (L) Discharge or transfer information. Documents, prepared upon a resident’s discharge or transfer from the facility, summarizing, when appropriate:

DHS 132.45(5)(L)1. 1. Current medical findings and condition;

DHS 132.45(5)(L)2. 2. Final diagnoses;

DHS 132.45(5)(L)3. 3. Rehabilitation potential;

DHS 132.45(5)(L)4. 4. A summary of the course of treatment;

DHS 132.45(5)(L)5. 5. Nursing and dietary information;

DHS 132.45(5)(L)6. 6. Ambulation status;

DHS 132.45(5)(L)7. 7. Administrative and social information; and

DHS 132.45(5)(L)8. 8. Needed continued care and instructions.

DHS 132.45(6) (6) Other records. The facility shall retain:

DHS 132.45(6)(a) (a) Dietary records. All menus and therapeutic diets;

DHS 132.45(6)(b) (b) Staffing records. Records of staff work schedules and time worked;

DHS 132.45(6)(c) (c) Safety tests. Records of tests of fire detection, alarm, and extinguishment equipment;

DHS 132.45(6)(d) (d) Resident census. At least a weekly census of all residents, indicating numbers of residents requiring each level of care;

DHS 132.45(6)(e) (e) Professional consultations. Documentation of professional consultations by:

DHS 132.45(6)(e)1. 1. A dietitian, if required by s. DHS 132.63 (2) (b);

DHS 132.45(6)(e)2. 2. A registered nurse, if required by s. DHS 132.62 (2); and

DHS 132.45(6)(e)3. 3. Others, as may be used by the facility;

DHS 132.45(6)(f) (f) Inservice and orientation programs. Subject matter, instructors and attendance records of all inservice and orientation programs;