S.D. Admin. R. 44:76:05:01

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

Section 44:76:05:01 - Admissions

Each patient may be admitted only on the order of a practitioner and the patient's health care shall continue under the supervision of a physician who is a member of the medical staff. Before or on admission of a patient, the patient's physician shall provide the staff of the facility with documented information regarding current medical findings, admitting diagnoses, and written orders for the immediate care of the individual.

The ambulatory surgery center must develop and maintain a policy that identifies those patients who require a medical history and physical examination prior to surgery. The policy must include:

(1) The timeframe for medical history and physical examination to be completed prior to surgery; and

(2) Address:

(A) Patient age;

(B) Diagnosis;

(C) Type and number of procedures scheduled to be performed on the same surgery date;

(D) Known comorbidities; and

(E) Planned anesthesia level; and

(3) Be based on any applicable nationally recognized standards of practice and guidance, and any applicable state and local health and safety laws. The patient's history and physical examination shall be completed and placed in the medical record prior to surgery except in emergency situations. In emergency situations when a completed history and physical examination cannot be completed prior to surgery, a brief admission note on the patient record is necessary. The note shall include at minimum critical information about the patient's condition, including pulmonary status, cardiovascular status, blood pressure, and vital signs. The history and physical examination shall specifically state the patient and anesthesia choice is appropriate for the ambulatory surgery center setting.

S.D. Admin. R. 44:76:05:01

42 SDR 51, effective 10/13/2015; 48 SDR 059, effective 12/5/2021

General Authority: SDCL 34-12-13(6).

Law Implemented: SDCL 34-12-13(6).