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;