ARSD 44:75:11:02. Surgical records

When surgery is performed, the following record requirements apply: (1) An operating room register must be complete and up to date. It must at a minimum include; patient name, hospital identification number, date of operation, inclusive or total time of operation, name of surgeon and any assistants, name of nursing personnel, type of anesthesia and name of person administering, operation performed, pre and post-operative diagnosis, and patient age; (2) The patient's medical record is available in the surgical suite at the time of surgery. The record must contain: (a) The patient's medical history; (b) A copy of the physician's examination; (c) A copy of laboratory tests; (d) A signed consent for the surgical procedure to be performed; and (e) A preoperative diagnosis; and (3) The operating surgeon shall record an accurate and complete description of the operative procedure within forty-eight hours of the completion of surgery.