Clinical record – Wis. Admin. Code DHS §131-33

Clinical records by hospices

This law describes in detail the clinical records that hospices are required to maintain for every patient.  The law generally requires a complete and single record for every patient that is to remain confidential except as required by law or third-party payment contract.  The law requires that the record be readily and promptly accessible to all persons providing services to the patient or patient’s family.

With respect to the content of this clinical record, the law requires that the following be included in each record:

• Initial and updated plans of care
• Initial and updated comprehensive assessments
• Documentation of all services provided to the patient or patient's family
• Signed copies of notice of patient's rights
• Medications list and responses to medications and treatments
• Physician certification and recertification of terminal illness
• Statement about whether patient has prepared an advance directive, and copy of advance directive, if available
• Physician's orders
• Patient and family identification information
• Transfer and discharge summaries

The law further sets forth specific rules for authentication and maintenance of these clinical records. 

• All records are required to be legible, dated and authenticated by person making the entry, including the person’s title and name
• Written record of every service provided must be included in the record within 7 days of date of service
• Medical symbols and abbreviations are allowed as long as a written policy defines the symbols and abbreviations
• Hospices must have written policies protecting the records against loss, destruction and unauthorized use

Original clinical records, copies of court orders and documents authorizing another person to act on behalf of patient must be maintained for at least 5 years after discharge or death; all other records must be maintained for at least 2 years after discharge or death