South Dakota Administrative Rules
Title 20 - PUBLIC SAFETY
Article 20:47 - PHYSICIANS AND SURGEONS
Chapter 20:47:07 - Medical record documentation
Section 20:47:07:03 - Best practices for medical records when prescribing controlled substances for the treatment of pain

(1) Copies of the signed informed consent and treatment agreement required by ARSD 20:47:07:01(3), (4) and (6);

(2) The patients medical history;

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

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

(5) 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 or telephoned;

(6) Instructions to the patient, including discussions of risks and benefits with the patient and any significant others, and written instructions for the use of all medications;

(7) Results of ongoing assessments of patient progress or lack of progress in terms of pain management and functional improvement;

(8) Notes on evaluations by and consultations with specialists;

(9) Any other information used to support the initiation, continuation, revision, or termination of treatment and the steps taken in response to any aberrant medication use behaviors;

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

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

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