South Dakota Administrative Rules
Title 20 - PUBLIC SAFETY
Article 20:47 - PHYSICIANS AND SURGEONS
Chapter 20:47:07 - Medical record documentation
Section 20:47:07:01 - Standards for medical records when prescribing controlled substances for the treatment of chronic, non-cancer pain

(1) Copies of the signed informed consent and any treatment agreement required by the physician;

(2) The patients medical and psychosocial history;

(3) The results of all physical examinations and all laboratory tests;

(4) Confirmation that the appropriate state prescription drug monitoring program has been accessed, and the date of that access, or an explanation why it was not accessed;

(5) The results of all risk assessments, including results of any screening instruments used;

(6) A description of the treatments provided, including all medications prescribed or administered, with the date of prescription or administration, the name and type of the medication, and the dosage and quantity of medication prescribed or administered. The medical records must include all prescription orders for opioid analgesics and other controlled substances, whether written, telephoned, faxed, or electronically transmitted;

(7) Instructions to the patient, including discussions with the patient and, if appropriate, significant others of the risks and benefits of opioid analgesics, including the risks of addiction, overdose, and death; proper use and storage of medication; proper disposal of unused medications; and the use of naloxone products to reverse overdose;

(8) Results of ongoing assessments, including, when appropriate, urine drug tests, of patient progress or lack of progress in terms of pain management and functional improvement;

(9) Notes on any evaluations by and consultations with specialists;

(10) Any other information used to support the initiation, continuation, revision, or termination of treatment; Any steps taken in response to aberrant medication use by a patient and aberrant behaviors related to a prescription for an opioid analgesic;

(11) Medical records of past hospitalizations or treatments by other providers, to the extent obtained by the physician;

(12) Authorization for release of information to other treatment providers; and

(13) Name, address, and telephone number of the patients pharmacy.