Wis. Admin. Code DHS § DHS 133.21

Current through March 24, 2024

Section DHS 133.21 - Medical records

(1) REQUIREMENT. A medical record shall be maintained on each patient and shall be completely and accurately documented, systematically organized and readily accessible to authorized personnel.

(2) SECURITY. Medical record information shall be safeguarded against loss, destruction or unauthorized use. Written procedures shall be established to control use and removal of records and to identify conditions for release of information.

Note: For information regarding confidentiality of patient health care records, see s. 146.82, Stats.

(3) RETENTION. For the purposes of this chapter medical records shall be retained for a minimum of 5 years following discharge. Arrangements shall be made for the storage and safekeeping of records if the agency goes out of business.

(4) TRANSFER. If a patient is transferred to another health facility or agency, a copy of the record or summary of the record shall be provided to the receiving agency or facility.

(5) CONTENT. The medical record shall document the patient's condition, problems, progress and services rendered, and shall include:

(a) Patient identification information.

(b) Appropriate hospital information (discharge summary, diagnosis, current patient status, post-discharge plan of care).

(c) Patient evaluation and assessment.

(d) Plan of care.

(e) Physician's, advanced practice nurse prescriber's, or physician assistant's orders.

(f) Medication list and documentation of patient instructions.

(g) Progress notes, as frequently as necessary to document patient status and services provided.

(h) Summaries of reviews of the plan of care.

(i) Discharge summary, completed within 30 days following discharge.

(6) FORM OF ENTRIES. All entries in the medical record shall be legible, permanently recorded, dated and authenticated with the name and title of the person making the entry.

(7) ABBREVIATIONS. Medical symbols and abbreviations may be used in medical records if approved by a written agency policy which defines the symbols and abbreviations and controls their use.

Wis. Admin. Code Department of Health Services § DHS 133.21

Cr. Register, May, 1984, No. 341, eff. 6-1-84; CR 07-060: am. (5) (d), (e), (h) and (i) Register November 2007 No. 623, eff. 12-1-07.

Amended by, CR 16-077: am. (4), (5) (a) to (h) Register September 2017 No. 741 eff. 10-1-17; correction in (5) (b) made under s. 35.17, Stats., Register September 2017 No. 741, eff. 10/1/2017