The facility must ensure each medical record shows the condition of the patient from the time of admission until discharge and must include:

1. (1) Identification data;
2. (2) Consent forms, except when unobtainable, or in an emergency;
3. (3) Inpatient and outpatient history;
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 each;
11. (11) A final diagnosis; and
12. (12) A discharge summary, including all discharge instructions for home care.

Source: 42 SDR 51, effective October 13, 2015 ; 50 SDR 62, effective November 27, 2023 .

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

Law Implemented: SDCL 34-12-13 .

Prior versions effective: 2015-10-13.