South Dakota Administrative Rules
Title 44 - Department of Health
Article 44:79 - Inpatient hospice facilities
Chapter 44:79:08 - Patient record services
Section 44:79:08:03 - Record content
Current through Register Vol. 50, page 114, March 25, 2024
Each medical record shall show the condition of the patient from the time of admission until discharge and shall include the following:
(1) Identification data;
(2) Consent forms, except when unobtainable;
(3) History of the patient;
(4) A current overall plan of care;
(5) Report of the initial and periodic physical examinations, evaluations, and all plans of care with subsequent changes;
(6) Diagnostic and therapeutic orders;
(7) Progress notes from all disciplines;
(8) Laboratory and radiology reports;
(9) Description of treatments, diet, and services provided and medications administered;
(10) All indications of an illness or an injury and change in condition, including the date, the time, and the action taken regarding each;
(10) Advanced directive;
(11) Physicians orders;
(12) Patients rights;
(13) A final diagnosis;
(14) A discharge summary; and
(15) Discharge instructions for home care when applicable.
General Authority: SDCL 34-12-13(10).
Law Implemented: SDCL 34-12-13(10).
