<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.s3584f3c4-dd16-46ef-97d9-4678c495568eP0 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: justify; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; } span.s3584f3c4-dd16-46ef-97d9-4678c495568eC0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002 { background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000003 { background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s3584f3c4-dd16-46ef-97d9-4678c495568e000004 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s3584f3c4-dd16-46ef-97d9-4678c495568eC3 { background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000005 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">    </span><a href="https://sdlegislature.gov/Rules?Rule=20:43:11:01"><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000000">20:43:11:01</span></a><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000001">.  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000001">Content</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000001">.</span><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0"> </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">A dentist who treats patients shall maintain legible, complete, and accurate medical records.</span><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000003"> </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">The medical record must contain the patient s clinical and financial record.</span><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000003"> </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">The clinical record must contain the following information</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">:</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568e000004"> </span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">    </span><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">(1)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">For each clinical record entry note</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">:</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">        (a)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">The signature, initials, or electronic verification of the individual that made the entry note; and</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">        (b)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">If treatment was provided, the name and the signature, initials, or electronic verification of the individual that provided treatment</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">;</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">    </span><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">(2)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">The date of each patient record entry, document, radiograph or model</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">;</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">    (3)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">The examination findings documented by subjective complaints, objective findings, an assessment or diagnosis of the patient's condition, and proposed treatment options</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">;</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">    (4)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">Current dental and medical history that may affect dental treatment</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">;</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">    (5)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">Any images, radiographs, test results or other diagnostic aid used to aid in the diagnosis. All film or digital radiographs must be of diagnostic quality. Retention of molds or study models is at the discretion of the dentist, except for molds or study models for orthodontia or full mouth reconstruction that must be retained as part of the clinical record</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">;</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">    (6)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">An agreed upon treatment plan based on the assessment or diagnosis of the patient's condition</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">;</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">    (7)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">A complete description of all treatment or procedures administered to the patient at each visit</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">;</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">    (8)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">A record of any medication administered or dispensed in office, or prescribed, including</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">:</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">        (a)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">The date administered, dispensed, or prescribed</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">;</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">        (b)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">The name of t</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC3">he patient to which the medication was administered, dispensed, or prescribed</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC3">;</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC3">        (c)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">The name of the medication; and</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">        (d)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">The dosage and amount of the medication administered, dispensed, or prescribed, including refills</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">;</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">    (9)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">Referrals, patient response to referrals, and any communication to and from any health care provider regarding the patient</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">;</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">    (10)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">Notation of communication to and from the patient or patient's parent or guardian, including</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">:</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">        (a)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">Notation of informed consent, including communication of potential risks and benefits of proposed treatment, recommended tests, and alternatives to treatment, including no treatment or tests</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">;</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">        (b)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">Notation of post-treatment instructions or reference to an instruction pamphlet given to the patient</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">;</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">        (c)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">Notation regarding patient complaints or concerns associated with treatment, including complaints or concerns obtained in person, by phone call, mail, electronic communication, or digital communication; and</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">        (d)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">Termination of the doctor-patient relationship; and</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">    (11)  </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">A copy of, or notation regarding, each laboratory order</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000002">.</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568e000004"> </span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">    </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000001">Source:</span><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0"> </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">50 SDR 125</span><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">, effective </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">May 8, 2024</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">.</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">    </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000001">General Authority:</span><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=36-6A-14"><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000005">36-6A-14</span></a><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">(20).</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">    </span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000001">Law Implemented:</span><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=36-6A-1"><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000005">36-6A-1</span></a><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">(6), </span><a href="https://sdlegislature.gov/Statutes?Statute=36-6A-14"><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0-000005">36-6A-14</span></a><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">(1)</span><span class="s3584f3c4-dd16-46ef-97d9-4678c495568eC0">.</span></p><p dir="ltr" class="s3584f3c4-dd16-46ef-97d9-4678c495568eP0"><span xml:space="preserve" class="s3584f3c4-dd16-46ef-97d9-4678c495568e000004"> </span></p></div></body></html>