Header:
WISCONSIN ADMINISTRATIVE CODE
DEPARTMENT OF HEALTH SERVICES
CHAPTER DHS 134. FACILITIES SERVING PEOPLE WITH DEVELOPMENTAL DISABILITIES
SUBCHAPTER III -- MANAGEMENT
Date:
08/31/2009
Document:
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 mental retardation 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.
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