S.D. Admin. R. 44:76:08:04

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

Section 44:76:08:04 - 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 in procedures determined emergencies;

(3) History of the patient;

(4) Any allergies and abnormal drug reactions;

(5) Entries related to anesthesia administration;

(6) A current overall plan of care;

(7) Report of the initial and periodic physical examinations, evaluations, and all plans of care with subsequent changes;

(8) Diagnostic and therapeutic orders;

(9) Progress notes from all disciplines;

(10) Laboratory and radiology reports;

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

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

(13) An operative report with findings and techniques of the operation that include pre-operative and postoperative diagnosis; and

(14) Discharge diagnosis, including all discharge instructions for home care.

S.D. Admin. R. 44:76:08:04

42 SDR 51, effective 10/13/2015

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

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