44:76:08:01.  Medical record department. There shall be an organized medical record system. A medical record shall be maintained for each level of care for each patient admitted to the facility.

          Source: 42 SDR 51, effective October 13, 2015.

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

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

          44:76:08:02.  Medical record department staff. The medical record functions shall be performed by persons 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: 42 SDR 51, effective October 13, 2015.

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

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

          44:76:08:03.  Written policies and confidentiality of records. There shall be written policies and procedures to govern the administration and activities of the medical record service. They shall include policies and procedures pertaining to the confidentiality and safeguarding of medical records, the record content, continuity of a patient's medical records during subsequent admissions, requirements for completion of the record, and the entries to be made by various authorized personnel.

          Source: 42 SDR 51, effective October 13, 2015.

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

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

          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.

          Source: 42 SDR 51, effective October 13, 2015.

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

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

          44:76:08:05.  Authentication. A facility shall ensure entries to the medical record timed, dated and 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: 42 SDR 51, effective October 13, 2015.

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

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

          44:76:08:06.  Retention of medical records. A facility shall retain medical records for a minimum of ten years from the actual visit date of service or patient care. The retention of the record for ten years is not affected by additional and future visit dates. Records of minors shall be retained until the minor reaches the age of majority plus an additional two years, but no less than ten years from the actual visit date of service or patient care. The retention of the record for ten years is not affected by additional and future visit dates.

          Source: 42 SDR 51, effective October 13, 2015.

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

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

          Cross-Reference: Storage of medical records, § 44:76:08:07.

          44:76:08:07.  Storage of medical records. A facility shall provide for filing, safe storage, and easy accessibility of medical records. The medical records shall be preserved as original records or in other readily retrievable and reproducible form. Medical records shall be protected against access by unauthorized individuals. All medical records shall be retained by the health care facility upon change of ownership.

          Source: 42 SDR 51, effective October 13, 2015.

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

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

          Cross-Reference: Disposition of medical records on closure of facility or transfer of ownership, § 44:76:08:09.

          44:76:08:08.  Destruction of medical records. After the minimum retention period of ten years from the actual visit date of care outlined in § 44:76:09:06, the medical record may be destroyed at the discretion of the health care facility. Before the destruction of the medical record, the facility shall prepare and retain a patient index or abstract. The patient index or abstract shall include:

          (1)  Name;

          (2)  Medical record number;

          (3)  Date of birth;

          (4)  Summary of visit dates;

          (5)  Attending or admitting physician; and

          (6)  Diagnosis or diagnosis code.

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

          Source: 42 SDR 51, effective October 13, 2015.

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

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

          44:76:08:09.  Disposition of medical records on closure of facility or transfer of ownership. If a facility ceases operation, the facility shall provide for safe storage and prompt retrieval of medical records and the patient indexes specified in § 44:76:09:08. The facility may arrange storage of medical records with another facility of the same licensure classification, transfer medical records to another health care provider at the request of the patient, relinquish medical records to the patient's parent or legal guardian, or arrange storage of remaining medical records with a third party vendor who undertakes such a storage activity. At least 30 days before closure, the facility shall notify the department in writing indicating the provisions for the safe preservation of medical records and their location and publish in a local newspaper the location and disposition arrangements of the medical records.

          If ownership of the facility is transferred, the new owner shall maintain the medical records as if there was not a change in ownership.

          Source: 42 SDR 51, effective October 13, 2015.

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

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

          Cross-Reference: Storage of medical records, § 44:76:08:07.