ARSD 44:76:08:04. Record content

Each medical record shall show the condition of the patient from the time of admission until discharge and shall include the following: (1) Identification data; (2) Consent forms, except in procedures determined emergencies; (3) History of the patient; (4) Any allergies and abnormal drug reactions; (5) Entries related to anesthesia administration; (6) A current overall plan of care; (7) Report of the initial and periodic physical examinations, evaluations, and all plans of care with subsequent changes; (8) Diagnostic and therapeutic orders; (9) Progress notes from all disciplines; (10) Laboratory and radiology reports; (11) Description of treatments, diet, and services provided and medications administered; (12) All indications of an illness or an injury, including the date, the time, and the action taken regarding each; (13) An operative report with findings and techniques of the operation that include pre-operative and postoperative diagnosis; and (14) Discharge diagnosis, including all discharge instructions for home care.