Medical records – Wis. Admin. Code DHS §133-21

A home health agency must maintain a complete and accurate clinical record for each patient.  The clinical record information must be easily accessible.  The records must be kept in a safe and secure location, protected against damage or unauthorized use.  The clinical record must be kept for at least 5 years after death or discharge of the patient.  The record must contain the following information:

•          Patient identification information;
•          Assessments;
•          Hospital information;
•          Plan of care;
•          Physician’s orders;
•          Medication lists;
•          Transfer or discharge summaries;