<html> <head> <title>Rule 44:76:08:04 Record content.</title> <META NAME="Keywords" Content="Administrative Rules 44:76:08:04"> <META NAME="Description" Content="Administrative Rules 44:76:08:04 Record content."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; punctuation-wrap:simple; text-autospace:none; font-size:10.0pt; font-family:"Times","serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><a name="_GoBack"></a><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>44:76:08:04.&nbsp;&nbsp;Record content.</b> Each medical record shall show the condition of the patient from the time of admission until discharge and shall include the following:</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;Identification data;</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;Consent forms, except in procedures determined emergencies;</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (3)&nbsp;&nbsp;History of the patient;</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (4)&nbsp;&nbsp;Any allergies and abnormal drug reactions;</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (5)&nbsp; Entries related to anesthesia administration;</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (6)&nbsp;&nbsp;A current overall plan of care;</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (7)&nbsp;&nbsp;Report of the initial and periodic physical examinations, evaluations, and all plans of care with subsequent changes;</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (8)&nbsp;&nbsp;Diagnostic and therapeutic orders;</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (9)&nbsp;&nbsp;Progress notes from all disciplines;</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (10)&nbsp;&nbsp;Laboratory and radiology reports;</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (11)&nbsp;&nbsp;Description of treatments, diet, and services provided and medications administered;</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (12)&nbsp;&nbsp;All indications of an illness or an injury, including the date, the time, and the action taken regarding each;</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (13)&nbsp;&nbsp;An operative report with findings and techniques of the operation that include pre-operative and postoperative diagnosis; and</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (14)&nbsp;&nbsp;Discharge diagnosis, including all discharge instructions for home care.</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 42 SDR 51, effective October 13, 2015.</span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=34-12-13">34-12-13(10).</A></span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=34-12-13">34-12-13(10).</A></span></p> <p class=MsoNormal style='text-align:justify;line-height:12.0pt'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> </div> </body> </html>