Each medical record shall show the condition of the patient from the time of admission until discharge and shall include the following:

1. (1) Identification data;
2. (2) Consent forms, except in procedures determined emergencies;
3. (3) History of the patient;
4. (4) Any allergies and abnormal drug reactions;
5. (5) Entries related to anesthesia administration;
6. (6) A current overall plan of care;
7. (7) Report of the initial and periodic physical examinations, evaluations, and all plans of care with subsequent changes;
8. (8) Diagnostic and therapeutic orders;
9. (9) Progress notes from all disciplines;
10. (10) Laboratory and radiology reports;
11. (11) Description of treatments, diet, and services provided and medications administered;
12. (12) All indications of an illness or an injury, including the date, the time, and the action taken regarding each;
13. (13) An operative report with findings and techniques of the operation that include pre-operative and postoperative diagnosis; and
14. (14) Discharge diagnosis, including all discharge instructions for home care.

Source: 42 SDR 51, effective October 13, 2015.

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

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