S.D. Admin. R. 44:79:08:03

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

Section 44:79:08:03 - Record content

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

(1) Identification data;

(2) Consent forms, except when unobtainable;

(3) History of the patient;

(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;

(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 and change in condition, including the date, the time, and the action taken regarding each;

(10) Advanced directive;

(11) Physicians orders;

(12) Patients rights;

(13) A final diagnosis;

(14) A discharge summary; and

(15) Discharge instructions for home care when applicable.

S.D. Admin. R. 44:79:08:03

42 SDR 51, effective 10/13/2015

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

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