S.D. Admin. R. 44:73:09:04

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

Section 44:73:09:04 - Record content

The facility must ensure each medical record indicates the condition of the resident from the time of admission until discharge and that each medical record contains:

(1) Identification data;

(2) Consent forms, except when unobtainable, or in an emergency;

(3) History of the resident;

(4) A current overall plan of care;

(5) A report of the initial and periodic physical examinations, evaluations, and all plans of care with subsequent changes;

(6) Diagnostic and therapeutic orders;

(7) Progress notes from practitioners of all disciplines;

(8) Laboratory and radiology reports;

(9) A description of treatments, diet, and services provided and medications administered;

(10) All indications of an illness or an injury, including the date and time of the illness or injury, and the date and time of action taken on the illness or injury;

(11) A final diagnosis; and

(12) A discharge summary, including all discharge instructions for home care.

S.D. Admin. R. 44:73:09:04

42 SDR 51, effective 10/13/2015; 51 SDR 053, effective 11/11/2024

General Authority: SDCL 34-12-13.

Law Implemented: SDCL 34-12-13.