S.D. Admin. R. 44:75:09:04

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

Section 44:75:09:04 - Record content

Each medical record shall show the condition of the patient from the time of admission until discharge and shall include:

(1) Identification data;

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

(3) Inpatient and outpatient history;

(4) A current overall plan of care;

(5) 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 all disciplines, including practitioners, physical therapy, occupational therapy, and speech-language pathology;

(8) Laboratory and radiology reports;

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

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

(11) A final diagnosis; and

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

S.D. Admin. R. 44:75:09:04

42 SDR 51, effective 10/13/2015; 50 SDR 062, effective 11/27/2023

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

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