A provider must maintain a medical record on each recipient, which discloses the extent of services furnished under this article. Each page of the record must name or otherwise identify the recipient and each entry in the record must be signed and dated by the individual providing the care. If care is provided by an individual working under the supervision of another who is a participating provider, the supervising individual must countersign each entry. If the care is provided in an institution by one of its employees, the entry need not be countersigned unless the institutional provider is responsible for monitoring the provision of such health care. The individual's medical record must include the following additional items as applicable:

1. (1) Diagnoses, assessments, and evaluations;
2. (2) Case history and results of examinations;
3. (3) Plan of treatment or patient care plan;
4. (4) Quantities and dosages of drugs prescribed or administered;
5. (5) Results of diagnostic tests and examinations;
6. (6) Progress notes detailing the recipient's treatment responses, changes in treatment, and changes in diagnosis;
7. (7) A copy of any consultation report that is ordered for the recipient;
8. (8) Dates of hospitalization relating to the services provided;
9. (9) A copy of the summary of surgical procedures billed to the medical services program;
10. (10) The date on which the entry is made;
11. (11) The date on which the health service is provided; and
12. (12) The length of time spent with the recipient, if the amount paid for services depends on time spent with the recipient.

Source: 17 SDR 4, effective July 16, 1990; 19 SDR 177, effective May 24, 1993; 46 SDR 50, effective October 10, 2019.

General Authority: SDCL 28-6-1.

Law Implemented: SDCL 28-6-1(2).

Prior versions effective: 1993-05-24.