Each patient may be admitted only on the order of a practitioner, and the patient's health care shall continue under the supervision of a physician who is a member of the medical staff. Before or on admission of a patient, the patient's physician shall provide the staff of the facility with documented information regarding current medical findings, admitting diagnoses, and written orders for the immediate care of the individual.

1. (1) Include the timeframe for a medical history and physical examination to be completed prior to surgery;

2. (2) Address:

   1. (A) Patient age;
   2. (B) Diagnosis;
   3. (C) Type and number of procedures scheduled to be performed on the same surgery date;
   4. (D) Known comorbidities; and
   5. (E) Planned anesthesia level; and

3. (3) Be based on any applicable nationally recognized standards of practice and guidance, and any applicable state and local health and safety laws.

   The history and physical examination shall be completed and placed in the patient's medical record prior to surgery except in emergency situations. In emergency situations when a history and physical examination cannot be completed prior to surgery, a brief admission note on the patient record is necessary. The note must include pulmonary status, cardiovascular status, blood pressure, and vital signs. The history and physical examination shall state the patient and anesthesia choice is appropriate for the facility setting.

The facility shall develop and maintain a policy that identifies patients who require a medical history and physical examination prior to surgery. The policy must:

Source: 42 SDR 51, effective October 13, 2015 ; 48 SDR 59, effective December 5, 2021 .

General Authority: SDCL 34-12-13 (6).

Law Implemented: SDCL 34-12-13 .

Prior versions effective: 2015-10-13.