South Carolina Code of Regulations
Chapter 61 - DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Subchapter 61-78 - Standards for Licensing Hospices
Sec2 61-78.800 - PATIENT RECORDS
Section 61-78.800.802 - Content (II)

1. Consultations by physicians or other authorized healthcare providers;

2. Orders for all medication, care, treatment, services, and procedures from physicians or other authorized healthcare providers shall be completed prior to, or at the time of admission, and updated when revised. Verbal orders received shall include the date of receipt of the order, description of the order, and identification of the individual receiving the order;

3. Care, treatment, and services provided;

4. Medications administered and procedures followed if an error is made, to include adverse reactions;

5. The Hospice Facility shall document medication administration by including medication name, dosage, mode of administration, date, time, and the signature of the individual administering or supervising the taking of the medication. Initials are acceptable when they can be identified readily by signatures;

6. Notes of observation;

7. Time and circumstances of death or of discharge or transfer, including condition at discharge or transfer.