Wis. Admin. Code Department of Health Services DHS 131.33 - Clinical record
(1) GENERAL. A hospice shall establish a
single and complete clinical record for every patient. Clinical record
information shall remain confidential except as required by law or a
third-party payment contract.
(2)
DOCUMENTATION AND ACCESSIBILITY. The clinical record shall be completely
accurate and up-to-date, readily accessible to all individuals providing
services to the patient or the patient's family, or both, and shall be
systematically organized to facilitate prompt retrieval of
information.
(3) CONTENT. A
patient's clinical record shall contain all of the following:
(a) The initial, integrated and updated plans
of care prepared under s.
DHS
131.21.
(b) The initial, comprehensive and updated
comprehensive assessments.
(c)
Complete documentation of all services provided to the patient or the patient's
family or both, including:
1.
Assessments.
2.
Interventions.
3. Instructions
given to the patient or family, or both.
4. Coordination of activities.
(d) Signed copies of the notice of
patient rights under s.
DHS
131.19(1) (a) and service
authorization statement under s.
DHS
131.17(4) (b).
(e) A current medications list.
(f) Responses to medications, symptom
management, treatments, and services.
(g) Outcome measure data elements, as
described in s.
DHS
131.20(5).
(h) Physician certification and
recertification of terminal illness.
(i) A statement of whether or not the
patient, if an adult, has prepared an advance directive; and a copy of the
advance directive, if prepared.
(j)
Physician orders.
(k) Patient and
family identification information.
(L) Referral information, medical history and
pertinent hospital discharge summaries.
(m) Transfer and discharge
summaries.
(4)
AUTHENTICATION.
(a)
Entries.
All entries shall be legible, permanently recorded, dated and authenticated by
the person making the entry, and shall include that person's name and
title.
(b)
Written
record. A written record shall be made for every service provided on
the date the service is provided. This written record shall be incorporated
into the clinical record no later than 7 calendar days after the date of
service.
(c)
Medical
symbols. Medical symbols and abbreviations may be used in the clinical
records if approved by a written program policy which defines the symbols and
abbreviations and controls their use.
(d)
Protection of
information. Written record policies shall ensure that all record
information is safeguarded against loss, destruction and unauthorized
usage.
(e)
Retention and
destruction.
1. An original clinical
record and legible copy or copies of court orders or other documents, if any,
authorizing another person to speak or act on behalf of the patient shall be
retained for a period of at least 5 years following a patient's discharge or
death when there is no requirement in state law. All other records required by
this chapter shall be retained for a period of at least 2 years.
2. A hospice shall arrange for the storage
and safekeeping of records for the periods and under the conditions required by
this paragraph in the event the hospice closes.
3. If the ownership of a hospice changes, the
clinical records and indexes shall remain with the hospice.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
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