ARSD 44:70:08:01. Record service

Each facility shall maintain a care record on each resident; shall have written procedures for documentation, filing, and retrieval of records; and shall have written policies to safeguard the resident's records against destruction, loss, and unauthorized use. The resident care records shall include the following: (1) Admission and discharge data including disposition of unused medications; (2) Report of the physician's, physician assistant's, or nurse practitioner's admission physical evaluation for resident; (3) Physician, physician assistant, or nurse practitioner orders; (4) Medication entries; (5) Observations by personnel, resident physician, physician assistant, nurse practitioner, or other persons authorized to care for the resident; and (6) Documentation that assures the individual needs of residents are identified and addressed.