ARSD 44:79:08:03. 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 when unobtainable; (3) History of the patient; (4) A current overall plan of care; (5) 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 all disciplines; (8) Laboratory and radiology reports; (9) Description of treatments, diet, and services provided and medications administered; (10) All indications of an illness or an injury and change in condition, including the date, the time, and the action taken regarding each; (11) Advanced directive; (12) Physicians orders; (13) Patients' rights; (14) A final diagnosis; (15) A discharge summary; and (16) Discharge instructions for home care when applicable.