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

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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;

Current as of June 2015