Wisconsin Administrative Code › Department of Health Services › DHS 30-100 - Community Services › Chapter DHS 83 - Community-Based Residential Facilities › Subchapter VII - Resident Care and Services › Section DHS 83.42 - Resident records

Current through June 24, 2024
(1) The CBRF shall maintain a record for each
				  resident at the CBRF. Each record shall include all of the following:
(a) Resident's full name, sex, date of birth,
				  admission date and last known address.
(b) Name, address and telephone number of
				  designated contact person, and legal representative, if any.
(c) Medical, social, and, if any, psychiatric
				  history.
(d) Current personal
				  physician, if any.
(e) Results of
				  the initial health screening under s.
				  DHS
				  83.28(4) and subsequent health
				  examinations under s.
				  DHS
				  83.38(1) (g).
(f) Admission agreement.
(g) Documentation of significant incidents
				  and illnesses, including the dates, times and circumstances.
(h) Assessments completed as required under
				  s.
				  DHS
				  83.35(1).
(i) Individual service plan and resident
				  satisfaction evaluation.
(j)
				  Documentation to accurately describe the resident's condition, significant
				  changes in condition, changes in treatment and response to treatment.
(k) Results of the annual resident evacuation
				  evaluation.
(L) Documentation of
				  sensory impairment of the resident as required under s.
				  DHS 83.48(7)
				  (b).
(m) Summary of discharge information as
				  required under s.
				  DHS
				  83.31(7).
(n) Any department-approved resident-specific
				  waiver, variance or approval.
(o)
				  Physician's orders or other authorized practitioner's written orders for
				  nursing care, medications, rehabilitation services and therapeutic
				  diets.
(p) Current list of the type
				  and dosage of medications or supplements.
(q) Results of the quarterly psychotropic
				  medication assessments as required in s.
				  DHS
				  83.37(1) (h) 1.
(r) Documentation of administration of all
				  medications, supplements, the person administering the medications or
				  supplements, any side effects observed by the employee or symptoms reported by
				  the resident, the need for PRN medications and the resident's response, refusal
				  to take medication, omissions of medications, errors in the administration of
				  medications and drug reactions.
(s)
				  Photocopy of any court order or other document authorizing another person to
				  speak or act on behalf of the resident, or other legal documents as required
				  which affect the care and treatment of a resident.
(t) Documentation of all other services
				  including rehabilitation services, treatments and therapeutic diets.
(u) Completed notice of pre-admission
				  assessment requirement under s.
				  DHS
				  83.30.
(v)
				  Nursing care procedures and the amount of time spent each week by a registered
				  nurse or licensed practical nurse in performing the nursing care procedures.
				  Only time actually spent by the nurse with the resident may be included in the
				  calculation of nursing care time.
(w) Plans of care for terminally ill
				  residents.
(x) Date, time and
				  circumstances of the resident's death, including the name of the person to whom
				  the body is released.