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).