The facility must ensure each medical record indicates the condition of the resident from the time of admission until discharge and that each medical record contains:

1. (1) Identification data;
2. (2) Consent forms, except when unobtainable, or in an emergency;
3. (3) History of the resident;
4. (4) A current overall plan of care;
5. (5) A report of the initial and periodic physical examinations, evaluations, and all plans of care with subsequent changes;
6. (6) Diagnostic and therapeutic orders;
7. (7) Progress notes from practitioners of all disciplines;
8. (8) Laboratory and radiology reports;
9. (9) A description of treatments, diet, and services provided and medications administered;
10. (10) All indications of an illness or an injury, including the date and time of the illness or injury, and the date and time of action taken on the illness or injury;
11. (11) A final diagnosis; and
12. (12) A discharge summary, including all discharge instructions for home care.

Source: SL 1975, ch 16, § 1; 6 SDR 93, effective July 1, 1980; 14 SDR 81, effective December 10, 1987; 19 SDR 172, effective May 19, 1993; 26 SDR 96, effective January 23, 2000; transferred from § 44:04:09:05 , 42 SDR 51, effective October 13, 2015 ; 51 SDR 53, effective November 11, 2024 .

General Authority: SDCL 34-12-13 .

Law Implemented: SDCL 34-12-13 .

Prior versions effective: 2015-10-13.