Wis. Admin. Code Department of Health Services DHS 134.47 - Records
(1) DEPARTMENT ACCESS. The administrator of a
facility or the administrator's designee shall provide the department with any
information the department needs to determine if the facility is in compliance
with chs. 50, 51 and 55, Stats., and this chapter and shall provide reasonable
opportunities for an authorized representative of the department to examine
facility records to gather this information.
(2) STAFFING FOR RECORDS MANAGEMENT.
(a) A facility shall have sufficient numbers
of qualified records management staff and necessary support personnel available
to accurately process, check, index, file and promptly retrieve records and to
record data.
(b) Duties specified
in this section that relate to resident records shall be completed by staff in
a timely manner.
(3)
GENERAL REQUIREMENTS CONCERNING RESIDENT RECORDS.
(a)
Organization. The
facility shall maintain a systematically organized record system appropriate to
the nature and size of the facility for the collection and release of
information about residents.
(b)
Unit record. A resident record shall be maintained for each
resident. The record shall be available and maintained on the unit on which the
individual resides.
(c)
Index. A master alphabetical resident record index shall be
maintained at a central location.
(d)
Confidentiality. The
facility shall ensure that all information contained in resident records is
kept confidential pursuant to s.
51.30, Stats., and ch.
DHS 92, and shall protect the information against loss, destruction or
unauthorized use. In this connection:
1. The
facility shall have written policies to govern access to and duplication and
release of information from resident records; and
2. The facility shall obtain the written
consent of the resident or guardian before releasing information to
unauthorized individuals.
(e)
Availability of records.
Resident records of current residents shall be stored in the facility and shall
be easily accessible at all times to persons authorized to provide care and
treatment. Resident records of both current and past residents shall be readily
available to persons designated by statute or authorized by the resident to
obtain the release of the medical records.
(f)
Maintenance.
1. A resident record shall be adequate for
planning and evaluation of the resident's habilitation or rehabilitation
program, or both, and shall furnish documentary evidence of the resident's
progress in the program.
2. The
facility shall provide adequate space, equipment and supplies to review, index,
file and retrieve resident records.
(g)
Retention and
destruction.
1. The resident record
shall be completed and stored within 60 days following a resident's discharge
or death.
2. For purposes of this
chapter, a resident record, including a legible copy of any court order or
other document authorizing another person to speak or act on behalf of the
resident, shall be retained for a period of at least 5 years following a
resident's discharge or death.
3. A
resident's record may be destroyed after 5 years has elapsed following the
resident's discharge or death, provided that:
a. The confidentiality of the information is
maintained; and
b. The facility
permanently retains at least a record of the resident's identity, final
diagnosis, physician and dates of admission and discharge.
4. In the event that a facility closes, the
facility shall arrange for the storage and safekeeping of resident records for
the period and under the conditions required by this paragraph.
5. If the ownership of a facility changes,
the resident records and indexes shall remain with the facility.
Note: Although this chapter obliges a facility to retain a resident's record for only 5 years following the resident's discharge or death, ch. DHS 92 requires a facility to retain the record of an individual with developmental disabilities for at least 7 years. See s. DHS 92.12(1).
(h)
Preparation.
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:
a. The stamp or electronic
representation is used only by the person who makes the entry; and
b. The facility possesses a statement signed
by the person, certifying that only that person shall possess and use the stamp
or electronic representation.
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.
(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:
(a)
Admission information.
Information obtained on admission, including:
1. Name, date of admission, birth date and
place, citizenship status, marital status and social security number;
2. Father's name and birthplace and mother's
maiden name and birthplace;
3.
Names and addresses of parents, legal guardian and next of kin;
4. Sex, race, height, weight, color of hair,
color of eyes, identifying marks and recent photograph;
5. Reason for admission or
referral;
6. Type and legal status
of admission;
7. Legal competency
status;
8. Language spoken or
understood;
9. Sources of support,
including social security, veterans' benefits and insurance;
10. Religious affiliation, if any;
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
12. Any physician's concurrence under s.
DHS 134.52(2)
(c) concerning admission to the
facility.
(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) and (b). The summary
shall include:
1. The name and address of the
guardian or other person having authority to speak or act on behalf of the
resident;
2. The date on which the
authorization or consent takes effect and the date on which it
expires;
3. The express legal
nature of the authorization or consent and any limitations on it; and
4. 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:
1. The comprehensive
evaluation of the resident and written training and habilitation
objectives;
2. The annual review of
the resident's program by the interdisciplinary team;
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;
4. Professional and special
programs and service plans, evaluations and progress notes; and
5. 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:
1. Physician orders for:
a. Medications and treatments;
b. Diets;
c. Special or professional services;
and
d. Limitations on
activities;
2. Restraint
orders required under s.
DHS 134.60(5) (b);
3. Discharge or transfer records required
under s.
DHS 134.53(4)
(d);
4. Physician progress notes following each
physician visit required under s.
DHS 134.66(2) (b) 4.; and
5. The report on the resident's annual
physical examination.
(f)
Nursing service documentation. Documentation of nursing needs
and the nursing services provided, including:
1. The nursing care component of the
individual program plan reviewed and revised annually as required by s.
DHS 134.60(1) (c) 2;
2. Nursing notes as needed to document the
resident's condition:
3. Other
nursing documentation describing;
a. The
general physical and mental condition of the resident, including any unusual
symptoms or behavior;
b. All
incidents or accidents, including time, place, details of the incident or
accident, action taken and follow-up care;
c. Functional training and
habilitation;
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;
e. Height and
weight;
f. Food and fluid intake,
when the monitoring of intake is necessary;
g. Any unusual occurrences of appetite or
refusal or reluctance to accept diets;
h. Rehabilitative nursing measures
provided;
i. The use of restraints,
documentation for which is required under s.
DHS 134.60(5) (b) 8.;
j. Immunizations and other non-routine
nursing care given;
k. Any family
visits and contacts;
l. The
condition of a resident upon discharge; and
m. 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:
1.
Psychologists;
2. Speech
pathologists and audiologists; and
3. Occupational and physical
therapists.
(i)
Dental records. Dental records, as follows:
1. A permanent dental record for each
resident;
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
3. Dental summary progress reports recorded
as needed.
(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:
1.
A summary of habilitative, rehabilitative, medical, emotional, social and
cognitive findings and progress;
2.
A summary and current status report on special and professional treatment
services;
3. A summary of need for
continued care and of plans for care;
4. Nursing and nutritional
information;
5. Administrative and
social information;
6. An
up-to-date statement of the resident's account as required by s.
DHS 134.31(3) (c)
3.; and
7. 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.
(5) RECORD RETENTION.
(a) The facility shall retain resident
records as required under sub. (3) (g).
(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:
1. Copies of any court
orders or other documents authorizing another person to speak or act on behalf
of the resident; and
2. The
original copy of any resident consent document required under this chapter.
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).
(c) The facility shall retain all records not
directly related to resident care for at least 2 years. These shall include:
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;
2. All menus and records of
modified diets, including the average portion size of items;
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);
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;
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;
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;
7.
Medical transfer service agreements and agreements with outside agency service
providers; and
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.
Notes
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