Each facility shall maintain a care record on each resident; shall have written procedures for documentation, filing, and retrieval of records; and shall have written policies to safeguard the resident's records against destruction, loss, and unauthorized use. The resident care records shall include the following:

1. (1) Admission and discharge data including disposition of unused medications;
2. (2) Report of the physician's, physician assistant's, or nurse practitioner's admission physical evaluation for resident;
3. (3) Physician, physician assistant, or nurse practitioner orders;
4. (4) Medication entries;
5. (5) Observations by personnel, resident physician, physician assistant, nurse practitioner, or other persons authorized to care for the resident; and
6. (6) Documentation that assures the individual needs of residents are identified and addressed.

Source: SL 1975, ch 16, § 1; 4 SDR 14, effective September 14, 1997; 6 SDR 93, effective July 1, 1980; 14 SDR 81, effective December 10, 1987; 22 SDR 70, effective November 19, 1995; 27 SDR 59, effective December 17, 2000; 30 SDR 84, effective December 4, 2003; transferred from § 44:04:09:06, 38 SDR 115, effective January 9, 2012.

General Authority: 34-12-13(10).

Law Implemented: 34-12-13(10).