Nursing Home Records – Wis. Admin. Code DHS §132-45

Nursing Home Records

This law lists all the records that need to be maintained by licensed nursing homes in the state of Wisconsin.  The administrator is responsible for providing the department of health services with all required information to document the nursing home's compliance with relevant laws and regulations, and to provide the department with means to examine records and gather information.  The nursing home is required to maintain current and separate personnel records for each employee

The law then describes in detail the requirements for maintenance of medical records for the residents of nursing homes.   The law requires that a record be maintained in a timely manner for each resident and day care client.  Original medical records, copies of the records, and documents authorizing other individuals to make health care decisions on behalf of the resident must be retained for at least 5 years after resident's discharge or death.  All other records must be retained for at least 2 years after resident's discharge or death.

The law requires that all entries be recorded legibly, dated and authenticated by the person making the entry, and allows the use of a rubber stamp or electronic signature as long as they are only used by the person making the entry and the person signs a statement to that effect.  The law allows the person making the entries to use symbols and abbreviations as long as there is a written policy defining the symbols.

The law requires that the following information be included in the medical record for each resident:

• Identification information and a summary sheet
• Information to be recorded by physician

o   Details about the medical evaluation conducted by a physician at the time of admission (including a summary of prior treatment, current findings, diagnoses, prognosis)

o   All physician's orders with respect to medication, treatment, diet, rehabilitative services, limitations, restraint orders, discharge or transfer

o   Progress notes by physician after each visit

o   Annual physical examination records

o   Alternative visit schedule, if any, and reasons for alternative visit schedule

• Information to be recorded by the nursing service

o   History and assessment of resident's nursing needs

o   Initial care plan

o   Nursing notes

o   Documentation describing general physical and mental condition, all incidents and accidents, administration of medication, food and fluid intake, unusual occurrences with respect to appetite or diet, restorative nursing measures summary, summary of use of physical and chemical restraints, non-routine nursing care given, condition of resident upon discharge, time of death

• An assortment of additional records including but not limited to social service records, rehabilitative services records, dental service records, copies of court order or consent forms allowing someone other than the resident to consent on behalf of resident

The law further details a number of other records that the nursing home facility is required to maintain for the facility in general like dietary records, staffing records, resident census, safety tests conducted, etc.