Administrative Rule 44:73:09 | South Dakota Legislature

Source: SL 1975, ch 16, § 1; 6 SDR 93, effective July 1, 1980; 14 SDR 81, effective December 10, 1987; 22 SDR 70, effective November 19, 1995; transferred from § 44:04:09:01, repealed, 42 SDR 51, effective October 13, 2015.

44:73:09:01.01. Medical record. A facility shall have an organized medical record system. A facility shall maintain a medical record for each level of care for each resident admitted to the facility.

Source: SL 1975, ch 16, § 1; 6 SDR 93, effective July 1, 1980; 14 SDR 81, effective December 10, 1987; 22 SDR 70, effective November 19, 1995; 26 SDR 96, effective January 23, 2000; transferred from § 44:04:09:02, 42 SDR 51, effective October 13, 2015; 51 SDR 53, effective November 11, 2024.

General Authority: SDCL 34-12-13.

Law Implemented: SDCL 34-12-13.

44:73:09:02. Medical record personnel. A facility shall have medical record functions performed by personnel trained and equipped to facilitate the accurate processing, checking, indexing, filing, and retrieval of all medical records. The individual responsible for the medical records service shall have knowledge and training in the field of medical records.

Source: SL 1975, ch 16, § 1; 6 SDR 93, effective July 1, 1980; 14 SDR 81, effective December 10, 1987; 22 SDR 70, effective November 19, 1995; transferred from § 44:04:09:03, 42 SDR 51, effective October 13, 2015; 51 SDR 53, effective November 11, 2024.

General Authority: SDCL 34-12-13.

Law Implemented: SDCL 34-12-13.

44:73:09:03. Written policies and confidentiality of records. A facility shall have written policies and procedures for the medical record service that address the confidentiality and safeguarding of medical records, the record content, continuity of a resident's medical records during subsequent admissions, requirements for completion of the record, and the entries to be made by various authorized personnel.

Source: SL 1975, ch 16, § 1; 6 SDR 93, effective July 1, 1980; 14 SDR 81, effective December 10, 1987; 22 SDR 70, effective November 19, 1995; transferred from § 44:04:09:04, 42 SDR 51, effective October 13, 2015; 51 SDR 53, effective November 11, 2024.

General Authority: SDCL 34-12-13.

Law Implemented: SDCL 34-12-13.

44:73:09:04. Record content. The facility must ensure each medical record indicates the condition of the resident from the time of admission until discharge and that each medical record contains:

(1) Identification data;

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

(3) History of the resident;

(4) A current overall plan of care;

(5) A 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 practitioners of all disciplines;

(8) Laboratory and radiology reports;

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

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

(11) A final diagnosis; and

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

Source: SL 1975, ch 16, § 1; 6 SDR 93, effective July 1, 1980; 14 SDR 81, effective December 10, 1987; 19 SDR 172, effective May 19, 1993; 26 SDR 96, effective January 23, 2000; transferred from § 44:04:09:05, 42 SDR 51, effective October 13, 2015; 51 SDR 53, effective November 11, 2024.

General Authority: SDCL 34-12-13.

Law Implemented: SDCL 34-12-13.

Rule 44:73:09:05 Authentication.

44:73:09:05. Authentication. A facility shall ensure entries to the medical record are signed or electronically authenticated. If the facility permits any portion of the medical record to be generated by electronic or optical means, policies and procedures shall exist to prohibit the use of authentication by unauthorized users.

Source: 19 SDR 172, effective May 19, 1993; 27 SDR 59, effective December 17, 2000; 30 SDR 84, effective December 4, 2003; transferred from § 44:04:09:07, 42 SDR 51, effective October 13, 2015.

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

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

44:73:09:06. Retention of medical records. A facility shall retain medical records for a minimum of ten years from the date of established resident care. The facility shall retain the records of a minor until the minor reaches the age of majority plus an additional two years, but no less than ten years from the date of established resident care. Initial, annual, and significant-change resident assessment records required by § 44:73:06:10 must be retained for ten years from the date of established resident care. The retention of the record for ten years is not affected by additional and future visit dates.

Source: 19 SDR 172, effective May 19, 1993; 22 SDR 70, effective November 19, 1995; 26 SDR 96, effective January 23, 2000; 27 SDR 59, effective December 17, 2000; 28 SDR 83, effective December 16, 2001; 31 SDR 62, effective November 7, 2004; transferred from § 44:04:09:08, 42 SDR 51, effective October 13, 2015; 51 SDR 53, effective November 11, 2024.

General Authority: SDCL 34-12-13.

Law Implemented: SDCL 34-12-13.

Cross-Reference: Storage of medical records, § 44:73:09:07.

44:73:09:07. Storage of medical records. A facility shall provide for filing, safe storage, and easy accessibility of medical records. The medical records must be preserved as original records or in another readily retrievable and reproducible form. Medical records must be protected against access by unauthorized individuals. All medical records must be retained by the health care facility upon change of ownership.

Source: 19 SDR 172, effective May 19, 1993; 27 SDR 59, effective December 17, 2000; 30 SDR 84, effective December 4, 2003; transferred from § 44:04:09:09, 42 SDR 51, effective October 13, 2015; 51 SDR 53, effective November 11, 2024.

General Authority: SDCL 34-12-13.

Law Implemented: SDCL 34-12-13.

Cross-Reference: Disposition of medical records on closure of facility or transfer of ownership, § 44:73:09:09.

44:73:09:08. Destruction of medical records. After the required retention period outlined in § 44:73:09:06, the facility may, at its discretion, destroy the medical record. Before the destruction of the medical record, the facility shall prepare and retain a resident index or abstract. The resident index or abstract must include the resident's:

(1) Name;

(2) Medical record number;

(3) Date of birth;

(4) Summary of care dates;

(5) Attending or admitting physician, physician assistant, or nurse practitioner; and

(6) Diagnosis or diagnosis code.

The facility shall destroy the medical record in a way that maintains confidentiality.

Source: 19 SDR 172, effective May 19, 1993; 27 SDR 59, effective December 17, 2000; 31 SDR 62, effective November 7, 2004; transferred from § 44:04:09:10, 42 SDR 51 effective October 13, 2015; 51 SDR 53, effective November 11, 2024.

General Authority: SDCL 34-12-13.

Law Implemented: SDCL 34-12-13.

44:73:09:09. Disposition of medical records on closure of facility or transfer of ownership. If a facility ceases operation, the facility must provide for safe storage and prompt retrieval of medical records and the resident indexes specified in § 44:73:09:06. The facility may arrange storage of medical records with another health care facility of the same licensure classification, transfer medical records to another health care provider at the request of the resident or the resident's legal representative, relinquish medical records to the resident or the resident's legal representative, or arrange storage of remaining medical records with a third-party vendor who provides secure storage of health care records. At least sixty days before closure, the facility shall notify the department in writing indicating the provisions for the safe preservation of medical records and the record's location and publish in the nearest legal newspaper or share on the facility's website the location and disposition arrangements of the medical records.

If ownership of the facility is transferred, the new owner must maintain the medical records in accordance with this chapter.

Source: 19 SDR 172, effective May 19, 1993; 27 SDR 59, effective December 17, 2000; transferred from § 44:04:09:11, 42 SDR 51, effective October 13, 2015; 51 SDR 53, effective November 11, 2024.

General Authority: SDCL 34-12-13.

Law Implemented: SDCL 34-12-13.

Cross-Reference: Storage of medical records, § 44:73:09:07.

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