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 when unobtainable;
3. (3) History of the patient;
4. (4) A current overall plan of care;
5. (5) 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 all disciplines;
8. (8) Laboratory and radiology reports;
9. (9) Description of treatments, diet, and services provided and medications administered;
10. (10) All indications of an illness or an injury and change in condition, including the date, the time, and the action taken regarding each;
11. (11) Advanced directive;
12. (12) Physicians orders;
13. (13) Patients' rights;
14. (14) A final diagnosis;
15. (15) A discharge summary; and
16. (16) Discharge instructions for home care when applicable.

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

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

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