S.D. Admin. R. 20:43:11:02

Current through Register Vol. 51, page 57, November 12, 2024

Section 20:43:11:02 - Medical record - Editing

Clinical record entries must not be erased or deleted from the record, but may be edited or corrected as follows:

(1) If the medical record is a written record, entries must be edited with a single line drawn through the incorrect information. New or corrected information must be initialed and dated. The individual initialing the record must identify who the individual is on the written medical record; or

(2) If the medical record is an electronic record, a record audit trail must be maintained with the medical record that includes a time and date history of deletions, edits, and corrections to electronically signed or locked medical records.

S.D. Admin. R. 20:43:11:02

50 SDR 125, effective 5/8/2024

General Authority: SDCL 36-6A-14(20).

Law Implemented: SDCL 36-6A-1(6), 36-6A-14(1).