<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.s316ed49b-235c-422a-ba63-e3bde53a96a9P0 { margin-top: 0; line-height: 12.0pt; 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; } span.s316ed49b-235c-422a-ba63-e3bde53a96a9C0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s316ed49b-235c-422a-ba63-e3bde53a96a9C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s316ed49b-235c-422a-ba63-e3bde53a96a9C0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s316ed49b-235c-422a-ba63-e3bde53a96a9000002 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s316ed49b-235c-422a-ba63-e3bde53a96a9C0-000003 { 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="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=44:75:09:04"><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0-000000">44:75:09:04</span></a><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0-000001">.  Record content.</span><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0"> </span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">The facility must ensure e</span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">ach medical record show</span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">s</span><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0"> the condition of the patient from the time of admission until discharge and </span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">must</span><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0"> include:</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9000002"> </span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    (1)  Identification data;</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    (2)  Consent forms, except when unobtainable, or in an emergency;</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    (3)  </span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">Inpatient and outpatient history</span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">;</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    (4)  A current overall plan of care;</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    (5)  </span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">A r</span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">eport of the initial and periodic physical examinations, evaluations, and all plans of care with subsequent changes;</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    (6)  Diagnostic and therapeutic orders;</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    (7)  Progress notes from </span><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">practitioners of </span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">all disciplines;</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    (8)  Laboratory and radiology reports;</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    (9)  </span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">A d</span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">escription of treatments, diet, and services provided and medications administered;</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    (10)  All indications of an illness or an injury, including the date</span><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0"> and</span><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0"> time</span><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0"> of the illness or injury</span><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">, and the </span><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">date and time of </span><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">action taken </span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">on</span><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0"> each;</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    (11)  A final diagnosis; and</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    (12)  A discharge summary, including all discharge instructions for home care.</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9000002"> </span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    </span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0-000001">Source:</span><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0"> 42 SDR 51, effective October 13, 2015</span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">; 50 SDR 62, effective November 27, 2023</span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">.</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    </span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0-000001">General Authority:</span><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=34-12-13"><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0-000003">34-12-13</span></a><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">(10).</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">    </span><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0-000001">Law Implemented:</span><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=34-12-13"><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0-000003">34-12-13</span></a><span class="s316ed49b-235c-422a-ba63-e3bde53a96a9C0">.</span></p><p dir="ltr" class="s316ed49b-235c-422a-ba63-e3bde53a96a9P0"><span xml:space="preserve" class="s316ed49b-235c-422a-ba63-e3bde53a96a9000002"> </span></p></div></body></html>