DHS 83.42 Resident records.

(1) The CBRF shall maintain a record for each resident at the CBRF. Each record shall
include all of the following:
(a) Resident’s full name, sex, date of birth, admission date and
last known address.
(b) Name, address and telephone number of designated contact person, and legal representative, if any.
(c) Medical, social, and, if any, psychiatric history.
(d) Current personal physician, if any.
(e) Results of the initial health screening under s.
(4) and subsequent health examinations under s.
(f) Admission agreement.
(g) Documentation of significant incidents and illnesses,
including the dates, times and circumstances.
(h) Assessments completed as required under s. DHS 83.35
(i) Individual service plan and resident satisfaction evaluation.
(j) Documentation to accurately describe the resident’s condition, significant changes in condition, changes in treatment and
response to treatment.
(k) Results of the annual resident evacuation evaluation.
(L) Documentation of sensory impairment of the resident as
required under s. DHS 83.48 (7) (b).
(m) Summary of discharge information as required under s.
(n) Any department−approved resident−specific waiver, variance, or approval.
(o) Physician’s orders or other authorized practitioner’s written orders for nursing care, medications, rehabilitation services
and therapeutic diets.
(p) Current list of the type and dosage of medications or supplements.
(q) Results of the quarterly psychotropic medication assessments as required in s.
(r) Documentation of administration of all medications, supplements, the person administering the medications or supplements, any side effects observed by the employee or symptoms
reported by the resident, the need for PRN medications and the
resident’s response, refusal to take medication, omissions of medications, errors in the administration of medications, and drug reactions.
(s) Photocopy of any court order or other document authorizing another person to speak or act on behalf of the resident, or
other legal documents as required which affect the care and treatment of a resident.
(t) Documentation of all other services including rehabilitation
services, treatments, and therapeutic diets.
(u) Completed notice of pre−admission assessment requirement under s. DHS 83.30.
(v) Nursing care procedures and the amount of time spent each
week by a registered nurse or licensed practical nurse in performing the nursing care procedures. Only time actually spent by the
nurse with the resident may be included in the calculation of nursing care time.
(w) Plans of care for terminally ill residents.
(x) Date, time, and circumstances of the resident’s death,
including the name of the person to whom the body is released.
(2) The licensee shall ensure all resident records are adequately safeguarded against destruction, loss or unauthorized access or use.
(3) The employee in charge of each work shift shall have the
means to access resident records