Wis. Admin. Code DHS §83-42 - Resident Records - Community Based Residential Facilities

This law requires that Community Based Residential Facilities (CBRF) maintain a record for each resident, and the law provides an extensive list of items that must be included in the record: biographical information, medical history, current physician, results of initial health screening, admission agreement, documentation of incidents and illnesses, assessments, service plan and satisfaction evaluation, documentation of resident's condition and changes in condition in response to treatment, documentation of resident’s sensory impairment, summary of discharge information, any approved waived or approval, physician’s orders, list of medications, results of quarterly psychotropic medication assessments, documentation of medication administration, photocopy of any relevant court order, documentation of all other services resident received like rehabilitation services, completed notice of pre-admission assessment, nursing care procedures, plans of care for terminally ill residents, information about death.
 
The law requires that the facility ensure the safety of these records against loss or destruction or unauthorized access.