<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=44:76:08">44:76:08</a></b></p> <p align=center><b>&nbsp;</b></p> <p align=center><b>MEDICAL RECORD SERVICES</b></p> <p>Section</p> <p><a href="DisplayRule.aspx?Rule=44:76:08:01">44:76:08:01</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Medical record department.</p> <p><a href="DisplayRule.aspx?Rule=44:76:08:02">44:76:08:02</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Medical record department staff.</p> <p><a href="DisplayRule.aspx?Rule=44:76:08:03">44:76:08:03</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Written policies and confidentiality of records.</p> <p><a href="DisplayRule.aspx?Rule=44:76:08:04">44:76:08:04</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Record content.</p> <p><a href="DisplayRule.aspx?Rule=44:76:08:05">44:76:08:05</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Authentication.</p> <p><a href="DisplayRule.aspx?Rule=44:76:08:06">44:76:08:06</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Retention of medical records.</p> <p><a href="DisplayRule.aspx?Rule=44:76:08:07">44:76:08:07</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Storage of medical records.</p> <p><a href="DisplayRule.aspx?Rule=44:76:08:08">44:76:08:08</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Destruction of medical records.</p> <p><a href="DisplayRule.aspx?Rule=44:76:08:09">44:76:08:09</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Disposition of medical records on closure of facility or transfer of ownership.</p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 44:76:08:01 Medical record department.</title> <META NAME="Keywords" Content="Administrative Rules 44:76:08:01"> <META NAME="Description" Content="Administrative Rules 44:76:08:01 Medical record department."> <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>44:76:08:01.&nbsp;&nbsp;Medical record department.</b> There shall be an organized medical record system. A medical record shall be maintained for each level of care for each patient admitted to the facility.</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> <br /><hr><br /><html> <head> <title>Rule 44:76:08:02 Medical record department staff.</title> <META NAME="Keywords" Content="Administrative Rules 44:76:08:02"> <META NAME="Description" Content="Administrative Rules 44:76:08:02 Medical record department staff."> <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>44:76:08:02.&nbsp;&nbsp;Medical record department staff.</b> The medical record functions shall be performed by persons trained and equipped to facilitate the accurate processing, checking, indexing, filing, and retrieval of all medical records. The individual responsible for the medical records service shall have knowledge and training in the field of medical records.</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> <br /><hr><br /><html> <head> <title>Rule 44:76:08:03 Written policies and confidentiality of records.</title> <META NAME="Keywords" Content="Administrative Rules 44:76:08:03"> <META NAME="Description" Content="Administrative Rules 44:76:08:03 Written policies and confidentiality of records."> <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>44:76:08:03.&nbsp;&nbsp;Written policies and confidentiality of records.</b> There shall be written policies and procedures to govern the administration and activities of the medical record service. They shall include policies and procedures pertaining to the confidentiality and safeguarding of medical records, the record content, continuity of a patient's medical records during subsequent admissions, requirements for completion of the record, and the entries to be made by various authorized personnel.</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> <br /><hr><br /><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> <br /><hr><br /><html> <head> <title>Rule 44:76:08:05 Authentication.</title> <META NAME="Keywords" Content="Administrative Rules 44:76:08:05"> <META NAME="Description" Content="Administrative Rules 44:76:08:05 Authentication."> <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>44:76:08:05.&nbsp;&nbsp;Authentication.</b> A facility shall ensure entries to the medical record timed, dated and signed or electronically authenticated. If the facility permits any portion of the medical record to be generated by electronic or optical means, policies and procedures shall exist to prohibit the use of authentication by unauthorized users.</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> <br /><hr><br /><html> <head> <title>Rule 44:76:08:06 Retention of medical records.</title> <META NAME="Keywords" Content="Administrative Rules 44:76:08:06"> <META NAME="Description" Content="Administrative Rules 44:76:08:06 Retention of medical records."> <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>44:76:08:06.&nbsp;&nbsp;Retention of medical records.</b> A facility shall retain medical records for a minimum of ten years from the actual visit date of service or patient care. The retention of the record for ten years is not affected by additional and future visit dates. Records of minors shall be retained until the minor reaches the age of majority plus an additional two years, but no less than ten years from the actual visit date of service or patient care. The retention of the record for ten years is not affected by additional and future visit dates.</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> <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>Cross-Reference:</b> Storage of medical records, &#167;&nbsp;44:76:08:07.</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 44:76:08:07 Storage of medical records.</title> <META NAME="Keywords" Content="Administrative Rules 44:76:08:07"> <META NAME="Description" Content="Administrative Rules 44:76:08:07 Storage of medical records."> <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>44:76:08:07.&nbsp;&nbsp;Storage of medical records.</b> A facility shall provide for filing, safe storage, and easy accessibility of medical records. The medical records shall be preserved as original records or in other readily retrievable and reproducible form. Medical records shall be protected against access by unauthorized individuals. All medical records shall be retained by the health care facility upon change of ownership.</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> <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>Cross-Reference:</b> Disposition of medical records on closure of facility or transfer of ownership, &#167;&nbsp;44:76:08:09.</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 44:76:08:08 Destruction of medical records.</title> <META NAME="Keywords" Content="Administrative Rules 44:76:08:08"> <META NAME="Description" Content="Administrative Rules 44:76:08:08 Destruction of medical records."> <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>44:76:08:08.&nbsp;&nbsp;Destruction of medical records.</b> After the minimum retention period of ten years from the actual visit date of care outlined in &#167;&nbsp;44:76:09:06, the medical record may be destroyed at the discretion of the health care facility. Before the destruction of the medical record, the facility shall prepare and retain a patient index or abstract. The patient index or abstract shall include:</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;Name;</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;Medical record number;</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;Date of birth;</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;Summary of visit dates;</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;&nbsp;Attending or admitting physician; 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; (6)&nbsp;&nbsp;Diagnosis or diagnosis code.</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; The facility shall destroy the medical record in a way that maintains confidentiality.</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> <br /><hr><br /><html> <head> <title>Rule 44:76:08:09 Disposition of medical records on closure of facility or transfer of ownership.</title> <META NAME="Keywords" Content="Administrative Rules 44:76:08:09"> <META NAME="Description" Content="Administrative Rules 44:76:08:09 Disposition of medical records on closure of facility or transfer of ownership."> <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>44:76:08:09.&nbsp;&nbsp;Disposition of medical records on closure of facility or transfer of ownership.</b> If a facility ceases operation, the facility shall provide for safe storage and prompt retrieval of medical records and the patient indexes specified in &#167;&nbsp;44:76:09:08. The facility may arrange storage of medical records with another facility of the same licensure classification, transfer medical records to another health care provider at the request of the patient, relinquish medical records to the patient's parent or legal guardian, or arrange storage of remaining medical records with a third party vendor who undertakes such a storage activity. At least 30 days before closure, the facility shall notify the department in writing indicating the provisions for the safe preservation of medical records and their location and publish in a local newspaper the location and disposition arrangements of the medical records.</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; If ownership of the facility is transferred, the new owner shall maintain the medical records as if there was not a change in ownership.</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> <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>Cross-Reference:</b> Storage of medical records, &#167;&nbsp;44:76:08:07.</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>