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;
(11) Advanced directive;
(12) Physicians orders;
(13) Patients' rights;
(14) A final diagnosis;
(15) A discharge summary; and
(16) Discharge instructions for home care when applicable.
Source: 42 SDR 51, effective October 13, 2015.
General Authority: SDCL 34-12-13(10).
Law Implemented: SDCL 34-12-13(10).
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