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Wis. Admin. Code § DHS 133.21 — Medical records

WisconsinregulationWisconsin Department of Health Services· effective 1984-06-01

What this rule requires your agency to do

  • 1All entries shall be legible, permanently recorded, dated, and authenticated with the name and title of the person making the entry [DHS 133.21(6)].(Wis. Admin. Code § DHS 133.21 — Medical records)
  • 2The record shall include summaries of plan-of-care reviews and a discharge summary completed within 30 days following discharge [DHS 133.21(5)(h)-(i)].(Wis. Admin. Code § DHS 133.21 — Medical records)
  • 3A medical record shall be maintained on each patient, completely and accurately documented, systematically organized, and readily accessible to authorized personnel [DHS 133.21(1)].(Wis. Admin. Code § DHS 133.21 — Medical records)
  • 4Medical record information shall be safeguarded against loss, destruction, or unauthorized use, with written procedures controlling use, removal, and conditions for release of information [DHS 133.21(2)].(Wis. Admin. Code § DHS 133.21 — Medical records)
  • 5Medical symbols and abbreviations may be used only if approved by a written agency policy that defines them and controls their use [DHS 133.21(7)].(Wis. Admin. Code § DHS 133.21 — Medical records)
  • 6Medical records shall be retained a minimum of 5 years following discharge, and arrangements shall be made for storage and safekeeping if the agency goes out of business [DHS 133.21(3)].(Wis. Admin. Code § DHS 133.21 — Medical records)
  • 7If a patient is transferred to another health facility or agency, a copy or summary of the record shall be provided to the receiving agency or facility [DHS 133.21(4)].(Wis. Admin. Code § DHS 133.21 — Medical records)
  • 8The medical record shall document the patient's condition, problems, progress, and services rendered, including identification information, hospital information, evaluation/assessment, plan of care, physician/APNP/PA orders, medication list and patient instructions, and progress notes [DHS 133.21(5)(a)-(g)].(Wis. Admin. Code § DHS 133.21 — Medical records)

Applies to: personal care

Requires a complete, accurate, secured medical record for each patient, retained at least 5 years after discharge, transferred on patient transfer, and containing enumerated content (identification, assessment, plan of care, orders, medications, progress notes, plan reviews, and a discharge summary within 30 days). Governs legibility/authentication of entries and use of abbreviations. Framework topic: Clinical Records / Documentation.

Regulatory information, not legal advice — always confirm against the cited official source. Verification reduces error; it does not certify compliance.