S.D. Admin. R. 44:70:08:01

Current through Register Vol. 51, page 67, December 16, 2024

Section 44:70:08:01 - Record service

Each facility shall maintain a care record on each resident; shall have written procedures for documentation, filing, and retrieval of records; and shall have written policies to safeguard the resident's records against destruction, loss, and unauthorized use. The resident care records shall include the following:

(1) Admission and discharge data including disposition of unused medications;

(2) Report of the physician's, physician assistant's, or nurse practitioner's admission physical evaluation for resident;

(3) Physician, physician assistant, or nurse practitioner orders;

(4) Medication entries;

(5) Observations by personnel, resident physician, physician assistant, nurse practitioner, or other persons authorized to care for the resident; and

(6) Documentation that assures the individual needs of residents are identified and addressed.

S.D. Admin. R. 44:70:08:01

SL 1975, ch 16, § 1; 4 SDR 14, effective 9/14/1997; 6 SDR 93, effective 7/1/1980; 14 SDR 81, effective 12/10/1987; 22 SDR 70, effective 11/19/1995; 27 SDR 59, effective 12/17/2000; 30 SDR 84, effective 12/4/2003; transferred from § 44:04:09:06, 38 SDR 115, effective 1/9/2012.

General Authority:34-12-13(10).

Law Implemented:34-12-13(10).