<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.sc706e955-a67e-44e9-aee0-09d02fabae07P0 { 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.sc706e955-a67e-44e9-aee0-09d02fabae07C0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sc706e955-a67e-44e9-aee0-09d02fabae07C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sc706e955-a67e-44e9-aee0-09d02fabae07C0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sc706e955-a67e-44e9-aee0-09d02fabae07000002 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sc706e955-a67e-44e9-aee0-09d02fabae07C0-000003 { 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="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=44:75:11:02"><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0-000000">44:75:11:02</span></a><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0-000001">.  Surgical records.</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> When surgery is performed, the following record requirements apply:</span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07000002"> </span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">    (1)  An operating room register </span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">must</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> be complete and up to date. It </span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">must</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> at a minimum include; patient name, hospital identification number, date of operation, inclusive or total time of operation, name of surgeon and any assistants, name of nursing personnel, type of anesthesia and name of person administering, operation performed, pre and post-operative diagnosis, and patient</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> age</span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">;</span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07000002"> </span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">    (2)  The patient's medical record</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> is available in the surgical suite at the time of surgery. The record must contain:</span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07000002"> </span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">        (a)  The patient's</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> medical history</span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">;</span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">        (b)  A</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> copy of the physician's examination</span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">;</span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">        (c)  A copy</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> of laboratory tests</span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">;</span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">        (d)  A</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> signed consent for the surgical procedure to be performed</span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">;</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> and</span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">        (e)  A</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> preoperative diagnosis</span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">;</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> and</span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07000002"> </span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">    (3)  </span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">The operating surgeon shall record a</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">n accurate and complete description of the operative procedure within </span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">forty-eight</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> hours </span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">of the</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> completion of surgery.</span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07000002"> </span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">    </span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0-000001">Source:</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> SL 1975, ch 16, § 1; 6 SDR 93, effective July 1, 1980; 14 SDR 81, effective December 10, 1987; 22 SDR 70, effective November 19, 1995; 26 SDR 96, effective January 23, 2000; transferred from § </span><a href="https://sdlegislature.gov/Rules?Rule=44:04:11:02"><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0-000003">44:04:11:02</span></a><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">, 42 SDR 51, effective October 13, 2015</span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">; 50 SDR 62, effective November 27, 2023</span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">.</span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">    </span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0-000001">General Authority:</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=34-12-13"><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0-000003">34-12-13</span></a><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">(10)(12).</span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">    </span><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0-000001">Law Implemented:</span><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=34-12-13"><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0-000003">34-12-13</span></a><span class="sc706e955-a67e-44e9-aee0-09d02fabae07C0">.</span></p><p dir="ltr" class="sc706e955-a67e-44e9-aee0-09d02fabae07P0"><span xml:space="preserve" class="sc706e955-a67e-44e9-aee0-09d02fabae07000002"> </span></p></div></body></html>