44:75:09:04Record content.

The facility must ensure each medical record shows the condition of the patient from the time of admission until discharge and must include: (1) Identification data; (2) Consent forms, except when unobtainable, or in an emergency; (3) Inpatient and outpatient history; (4) A current overall plan of care; (5) A report of the initial and periodic physical examinations, evaluations, and all plans of care with subsequent changes; (6) Diagnostic and therapeutic orders; (7) Progress notes from practitioners of all disciplines; (8) Laboratory and radiology reports; (9) A description of treatments, diet, and services provided and medications administered; (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) A final diagnosis; and (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.