<html> <head> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p align=center><a name="_GoBack"></a><b>CHAPTER <a href="DisplayRule.aspx?Rule=44:76:05">44:76:05</a></b></p> <p align=center><b>&nbsp;</b></p> <p align=center><b>PHYSICIAN SERVICES</b></p> <p>Section</p> <p><a href="DisplayRule.aspx?Rule=44:76:05:01">44:76:05:01</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Admissions.</p> <p><a href="DisplayRule.aspx?Rule=44:76:05:02">44:76:05:02</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Medical orders.</p> <p><a href="DisplayRule.aspx?Rule=44:76:05:03">44:76:05:03</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Physician assistant, nurse practitioner, or clinical nurse specialist.</p> </div> </body> </html> <br /><hr><br /><html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>p.sc3dac548-80e1-43c9-ad54-eb5bd674480eP0 { 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.sc3dac548-80e1-43c9-ad54-eb5bd674480eC0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sc3dac548-80e1-43c9-ad54-eb5bd674480e000002 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sc3dac548-80e1-43c9-ad54-eb5bd674480eP0-000003 { 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; font-size: 12pt; } span.sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000004 { color: black; background: white; font-family: Times; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sc3dac548-80e1-43c9-ad54-eb5bd674480eP0-000005 { 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; font-size: 10pt; } span.sc3dac548-80e1-43c9-ad54-eb5bd674480e000006 { color: black; background: white; font-size: 10pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000007 { 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="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">    </span><a href="https://sdlegislature.gov/Rules?Rule=44:76:05:01"><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000000">44:76:05:01</span></a><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000001">.  Admissions.</span><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0"> Each patient may be admitted only on the order of a practitioner</span><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">,</span><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0"> and the patient's health care shall continue under the supervision of a physician who is a member of the medical staff. Before or on admission of a patient, the patient's physician shall provide the staff of the facility with documented information regarding current medical findings, admitting diagnoses, and written orders for the immediate care of the individual.</span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480e000002"> </span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0-000003"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">    </span><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">The facility shall develop and </span><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000004">maintain a policy that identifies patients who require a medical history and physical examination prior to surgery. The policy must:</span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0-000003"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480e000002"> </span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0-000003"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000004">    (1)  Include the timeframe for a medical history and physical examination to be completed prior to surgery;</span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0-000003"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000004">    (2)  Address:</span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0-000003"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000004">            (A)  Patient age;</span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0-000003"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000004">            (B)  Diagnosis;</span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0-000003"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000004">            (C)  Type and number of procedures scheduled to be performed on the same surgery date;</span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0-000003"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000004">            (D)  Known comorbidities; and</span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0-000003"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000004">            (E)  Planned anesthesia level; and</span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0-000003"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000004">    (3)  Be based on </span><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000004">any applicable nationally recognized standards of practice and guidance, and any applicable state and local health and safety laws.</span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0-000005"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480e000006"> </span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">    </span><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">The history and physical examination shall be completed and placed in the </span><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">patient's </span><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">medical record prior to surgery except in emergency situations. In emergency situations when a history and physical examination cannot be completed prior to surgery, a brief admission note on the patient record is necessary. The note </span><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">must</span><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0"> include pulmonary status, cardiovascular status, blood pressure, and vital signs. The history and physical examination shall state the patient and anesthesia choice is appropriate for the </span><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">facility</span><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0"> setting.</span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480e000002"> </span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">    </span><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000001">Source:</span><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0"> 42 SDR 51, effective October 13, 2015</span><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">; 48 SDR 59, effective December 5, 2021</span><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">.</span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">    </span><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000001">General Authority:</span><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=34-12-13"><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000007">34-12-13</span></a><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">(6).</span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">    </span><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000001">Law Implemented:</span><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=34-12-13"><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0-000007">34-12-13</span></a><span style="white-space: pre-wrap;" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eC0">.</span></p><p dir="ltr" class="sc3dac548-80e1-43c9-ad54-eb5bd674480eP0"><span style="white-space: pre-wrap;" xml:space="preserve" class="sc3dac548-80e1-43c9-ad54-eb5bd674480e000002"> </span></p></div></body></html><br /><hr><br /><html> <head> <title>Rule 44:76:05:02 Medical orders.</title> <META NAME="Keywords" Content="Administrative Rules 44:76:05:02"> <META NAME="Description" Content="Administrative Rules 44:76:05:02 Medical orders."> <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>44:76:05:02.&nbsp;&nbsp;Medical orders.</b> All medical orders, including verbal orders, shall be in writing or electronic format and shall be dated, timed, and authenticated promptly by the practitioner. Verbal orders are for medications, treatments, interventions, or other patient care that are transmitted as oral, spoken communications between senders and receivers, delivered either face-to-face or via telephone. Verbal orders may be taken only when there is an urgent need to initiate or change a medical order. The practitioner shall time, date, and authenticate the orders for all patients promptly. Each practitioner is responsible for documenting written or electronic orders and progress notes on each patient's medical record.</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(6).</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(6).</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> <br /><hr><br /><html> <head> <title>Rule 44:76:05:03 Physician assistant, nurse practitioner, or clinical nurse specialist.</title> <META NAME="Keywords" Content="Administrative Rules 44:76:05:03"> <META NAME="Description" Content="Administrative Rules 44:76:05:03 Physician assistant, nurse practitioner, or clinical nurse specialist."> <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>44:76:05:03.&nbsp;&nbsp;Physician assistant, nurse practitioner, or clinical nurse specialist.</b> If the services of a physician assistant, nurse practitioner, or clinical nurse specialist are utilized, the facility shall develop written policies regarding their role in the care 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;</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(6).</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(6).</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>