reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:02 - Food safety

Current through Register Vol. 51, page 10, July 15, 2024
Hot food shall be held at or above one hundred
				  thirty-five
degrees Fahrenheit or 57.2 degrees Centigrade and served
				  promptly after being removed from the temperature holding device. Cold foods
				  shall be held at or below forty-one degrees Fahrenheit or five degrees
				  centigrade and served promptly after being removed from the holding device.
				  Milk and milk products shall be from a source approved by the state Department
				  of Agriculture and Natural Resources. Fluid milk shall be Grade A, and only
				  fluid milk may be used for drinking purposes. Grade A pasteurized dried milk
				  may be used to fortify nutritional supplements only if consumed within four
				  hours of preparation.
General Authority:
SDCL
					 34-12-13(8).
Law Implemented:
SDCL
					 34-12-13(8).
Food Service Code, chapter
					 44:02:07.
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:03 - Nutritional adequacy

Current through Register Vol. 51, page 10, July 15, 2024
The dietetic service shall prepare food that is nutritionally
				  adequate in accordance with the recommended dietary allowances and is chosen
				  from each of the five basic food groups listed in the Dietary Guidelines for
				  Americans, 2020-2025, U.S. Department of Agriculture, in accordance with
				  consideration for individual needs and reasonable
				  preferences.
General Authority:
SDCL
					 34-12-13(8).
Law Implemented:
SDCL
					 34-12-13(8).
Dietary Guidelines for Americans, 2020-2025, United States
					 Department of Agriculture. Copies may be viewed and printed free of charge at
https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf
.
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:04 - Food substitutions

Current through Register Vol. 51, page 10, July 15, 2024
The facility shall offer reasonable substitutions of equal
				  nutritional value to patients who refuse or are unable to eat the food
				  served.
General Authority:
SDCL
					 34-12-13(8).
Law Implemented:
SDCL
					 34-12-13(8).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:05 - Food supply

Current through Register Vol. 51, page 10, July 15, 2024
The facility shall maintain an on-site supply of perishable
				  and nonperishable foods to meet the planned menus for three days. A facility
				  shall maintain additional nonperishable foods as part of their emergency
				  preparedness plan. A facility may use military meals ready to eat in an
				  emergency event according to the facility's emergency response
				  plan.
General Authority:
SDCL
					 34-12-13(8).
Law Implemented:
SDCL
					 34-12-13(8).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:06 - Therapeutic diets

Current through Register Vol. 51, page 10, July 15, 2024
In each facility the dietetic service shall provide for the
				  needs of those patients requiring therapeutic diets.
General Authority:
SDCL
					 34-12-13(8).
Law Implemented:
SDCL
					 34-12-13(8).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:08 - Written dietetic policies

Current through Register Vol. 51, page 10, July 15, 2024
The facility shall develop written policies and procedures
				  that govern all dietetic activities. Policies and procedures must include food
				  handling procedures, length of duration for leftovers, and opened packages of
				  commercially prepared food in accordance with chapter 44:02:07. The policies
				  and procedures shall be reviewed biennially and revised as
				  necessary.
General Authority:
SDCL
					 34-12-13(5)(8).
Law Implemented:
SDCL
					 34-12-13(5)(8).
Service Code, chapter
					 44:02:07.
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:09 - Written menus

Current through Register Vol. 51, page 10, July 15, 2024
Any regular and therapeutic menu, including therapeutic diet
				  menu extensions for all diets served in the facility, shall be written,
				  prepared, and served as prescribed by each patient's physician, physician
				  assistant, nurse practitioner, or dietitian. Each menu must be written at least
				  one week in advance. A dietitian shall annually review and approve each planned
				  menu for each facility. The dietitian shall review any menu changes from month
				  to month and each menu shall be reviewed and approved by the dietitian at least
				  annually. Each menu as served must meet the nutritional needs of the patient in
				  accordance with the orders of a physician, physician assistant, nurse
				  practitioner, or dietitian and the Dietary Guidelines for Americans 2020-2025,
				  United States Department of Agriculture. The facility shall file and retain a
				  record of each menu as served for thirty days.
General Authority:
SDCL
					 34-12-13(8).
Law Implemented:
SDCL
					 34-12-13(8).
Dietary Guidelines for Americans, 2020-2025, United States
					 Department of Agriculture. Copies may be viewed and printed free of charge at
https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary
					 Guidelinesformericans-2020-2025.pdf
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:10 - Preparation of food

Current through Register Vol. 51, page 10, July 15, 2024
Food shall be wholesome and prepared by methods that
				  conserve nutritive value, flavor, and appearance and shall be attractively
				  served at the temperature applicable to the particular food in a form to meet
				  the individual patient's needs.
General Authority:
SDCL
					 34-12-13(8).
Law Implemented:
SDCL
					 34-12-13(8).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:11 - Director of dietetic services

Current through Register Vol. 51, page 10, July 15, 2024
A general hospital, specialized hospital, or critical access
				  hospital shall have full-time dietary manager who is responsible to the
				  administrator to direct the dietetic services. Any dietary manager that has not
				  completed a Dietary Manager's course, approved by the Association of Nutrition
				  and Foodservice Professionals, shall enroll in a course within ninety days of
				  the hire date and complete the course within eighteen months. The dietary
				  manager and at least one cook shall successfully complete and possess a current
				  certificate from a ServSafe Food Protection Program offered by various
				  retailers, or the Certified Food Protection Professional's Sanitation Course
				  offered by the Association of Nutrition and Foodservice Professionals, or
				  successfully completed equivalent training as determined by the department.
				  Individuals seeking ServSafe recertification are only required to take the
				  national examination. The dietary manager shall monitor the dietetic service to
				  ensure that the nutritional and therapeutic dietary needs for each patient are
				  met. If the dietary manager is not a dietitian, the facility must schedule
				  dietitian consultations onsite at least monthly. The dietitian shall approve
				  all menus, assess the nutritional status of patients with problems identified
				  in the assessment, and review and revise dietetic policies and procedures
				  during scheduled visits. The facility shall have sufficient personnel whose
				  working hours are scheduled to meet the dietetic needs of the patients on duty
				  daily over a period of ten or more hours each day.
General Authority:
SDCL
					 34-12-13(8).
Law Implemented:
SDCL
					 34-12-13(8).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:12 - Hospitals without in-house dietary departments

Current through Register Vol. 51, page 10, July 15, 2024
Each hospital without an in-house dietary department shall
				  develop and maintain a written contract or agreement for dietary services for
				  the patients. The facility shall have a person responsible to the administrator
				  who monitors the receiving, storage, and service of the food to patients in
				  accordance with §
									44:75:07:02. The facility shall
				  have at least one full-time person who has completed the ServSafe Food
				  Protection Program and possesses a current certificate. Individuals seeking
				  ServSafe recertification are only required to take the national
				  examination.
Each hospital without an in-house dietary department shall
				  employ or contract a qualified dietitian and schedule a minimum of monthly
				  on-site consultations. The facility's dietitian shall review the facility's
				  food contract agreement and make recommendations. The facility's dietitian
				  shall review, sign, and approve menus annually. The facility's dietitian shall
				  review menus served monthly, oversee the operation of the dietetic services,
				  assess the nutritional status and needs of patients, and review and revise the
				  dietetic service policies and procedures.
General Authority:
SDCL
					 34-12-13(8).
Law Implemented:
SDCL
					 34-12-13(8).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:13 - Diet manual

Current through Register Vol. 51, page 10, July 15, 2024
A current therapeutic diet manual with description of all
				  diets served in the facility shall be readily available in the facility to food
				  service personnel, nursing service personnel, and
				  practitioners.
General Authority:
SDCL
					 34-12-13(8).
Law Implemented:
SDCL
					 34-12-13(8).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:14 - Frequency of meals

Current through Register Vol. 51, page 10, July 15, 2024
Each facility shall serve at least three meals at regular
				  times with not more than a 14-hour span between a substantial evening meal and
				  breakfast.
General Authority:
SDCL
					 34-12-13(8).
Law Implemented:
SDCL
					 34-12-13(8).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:15 - Feeding assistance

Current through Register Vol. 51, page 10, July 15, 2024
The facility shall provide feeding assistance for patients in
				  need of help in eating.
General Authority:
SDCL
					 34-12-13(8).
Law Implemented:
SDCL
					 34-12-13(8).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:16 - Nutritional screening and assessments

Current through Register Vol. 51, page 10, July 15, 2024
A licensed nurse or dietary manager shall complete a
				  nutritional screen upon each patient admission and make a referral to the
				  dietitian based on screening protocols related to nutritional risk of any
				  patient
(1) With a significant change
				in diet, eating ability, or nutritional status;
(2) Receiving tube feedings; or
(3) With a disease or condition, that puts
				the patient at significant nutritional risk.
A monthly tube feeding assessment shall include nutritional
				  adequacy of calories, protein, and fluids. An annual assessment shall be
				  completed for each swing bed patient.
General Authority:
SDCL
					 34-12-13.
Law Implemented:
SDCL
					 34-12-13.
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:07 - Dietetic Services › Section 44:75:07:17 - Required dietary inservice training

Current through Register Vol. 51, page 10, July 15, 2024
The hospital's dietary manager or the dietitian shall provide
				  ongoing inservice training for all dietary and food-handling personnel. The
				  person-in-charge of any hospital without an in-house dietary department that
				  uses a contracted dietary service shall provide ongoing inservice training for
				  all dietary and food-handling personnel. Training must be completed within
				  thirty days of hire and annually for any dietary or food-handling personnel and
				  must include the following subjects:
(1) Food safety;
(2) Handwashing;
(3) Food handling and preparation
				techniques;
(4) Food-borne
				illnesses;
(5) Serving and
				distribution procedures;
(6)
				Leftover food handling policies;
(7) Time and temperature controls for food
				preparation and service;
(8)
				Nutrition and hydration and;
(9)
				Sanitation requirements.
General Authority:
SDCL
					 34-12-13(8).
Law Implemented:
SDCL
					 34-12-13(8).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:08 - Medication Control › Section 44:75:08:01 - Policies and procedures

Current through Register Vol. 51, page 10, July 15, 2024
Each facility shall establish and implement written policies
				  and procedures for medication control that include:
(1) A requirement that each patient's
				prescribing physician, physician assistant, or nurse practitioner provide to
				the facility electronic or written signed orders for;
(a) Any medications taken by the
				patient;
(b) Authorization for
				medications or drugs kept on the patient or in the room of the patient;
				and
(c) Release of
				medications;
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:08 - Medication Control › Section 44:75:08:02 - Written orders for medication required

Current through Register Vol. 51, page 10, July 15, 2024
All medications administered to patients shall be ordered
				  electronically or in writing and dated, timed, and authenticated by the
				  prescriber. Verbal orders for medications or drugs may be taken only when there
				  is an urgent need to initiate or change an order and accepted only by a
				  pharmacist or licensed nurse in hospitals. The prescriber shall date, time, and
				  authenticate the orders for hospital patients on the next visit to the
				  facility. A policy on stop orders for antibiotics, anticoagulants, and
				  controlled drugs shall be established based on recommendations of the medical
				  staff.
General Authority:
SDCL
					 34-12-13(9).
Law Implemented:
SDCL
					 34-12-13(9).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:08 - Medication Control › Section 44:75:08:03

Current through Register Vol. 51, page 10, July 15, 2024
General Authority:
SDCL
					 34-12-13(9).
Law Implemented:
SDCL
					 34-12-13(9).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:08 - Medication Control › Section 44:75:08:04 - Storage and labeling of medications

Current through Register Vol. 51, page 10, July 15, 2024
All medications must be stored in a well illuminated, locked
				  storage area that is well ventilated, maintained at a temperature appropriate
				  for medication storage, and inaccessible to patients and visitors at all times.
				  Medications suitable for storage at room temperature shall be maintained
				  between fifty-nine and eighty-six degrees Fahrenheit or fifteen and thirty
				  degrees centigrade. Medications that require refrigeration shall be maintained
				  between thirty-six and forty-six degrees Fahrenheit or two and eight degrees
				  centigrade. Poisons and medications prescribed for external use must be stored
				  separately from medications prescribed for internal use, locked, and made
				  inaccessible to patients and visitors.
Locked storage does not apply to drugs and medications needed
				  for emergency use in intensive care, emergency room, neonatal intensive care,
				  pediatric intensive care, or coronary care units. Medications utilized in these
				  care units shall be in a storage area that is readily available to the
				  professional staff but inaccessible to patients or visitors.
The medication of each patient for whom medications are
				  facility-administered must be stored in the containers in which the medication
				  was originally received and may not be transferred to another container.
				  Special modification of this requirement may be made if single dose packaging
				  is used. Each prescription drug container, including manufacturer's
				  complimentary samples, must be labeled with the patient's name, physician,
				  physician assistant, or nurse practitioner's name, medication name and
				  strength, directions for use, and prescription date.
A container with a medication that will not be used within
				  thirty days of issue or with contents that expire in less than thirty days of
				  issue must bear an expiration date. If a single dose system is used, the
				  medication name and strength, expiration date, and a control number must be on
				  the unit dose packet.
A co-located hospital and assisted living center may procure
				  and stock, including in bulk form, nonlegend medications and administer them in
				  accordance with written policies and procedures that provide for oversight by
				  qualified personnel.
If a stock bottle system is used in a facility with a
				  licensed pharmacy, the container shall be labeled with the drug name and
				  strength, expiration date, and a control number. Any container with a worn,
				  illegible, or missing label shall be destroyed pursuant to §
									44:73:08:06. Licensed pharmacists
				  are responsible for the labeling, relabeling, or altering of labels on
				  medication containers.
General Authority:
SDCL
					 34-12-13(9).
Law Implemented:
SDCL
					 34-12-13(9).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:08 - Medication Control › Section 44:75:08:05 - Control and accountability of medications and drugs

Current through Register Vol. 51, page 10, July 15, 2024
Medications brought from a patient's home may be used if
				  ordered by the attending physician, physician assistant, or nurse practitioner,
				  and, if prior to administration, is identified as the prescribed medication.
				  Medications prescribed for one patient may not be administered to another.
				  Patients may not keep medications on their person or in their room without a
				  physician's, physician assistant, or nurse practitioner's order allowing
				  self-administration. The patient's physician, physician assistant, or nurse
				  practitioner must authorize the release of any medication to a patient upon
				  discharge, transfer, or temporary leave from the facility. The release of
				  medication must be documented in the patient's record, indicating quantity,
				  medication name, and strength. The facility shall maintain records that account
				  for all medications from their receipt through administration, destruction, or
				  return.
General Authority:
SDCL
					 34-12-13(9).
Law Implemented:
SDCL
					 34-12-13(9).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:08 - Medication Control › Section 44:75:08:06 - Documentation of drug disposal

Current through Register Vol. 51, page 10, July 15, 2024
Legend drugs not controlled under SDCL chapter 34-20 B shall
				  be destroyed or disposed of by a nurse and another witness. Destruction or
				  disposal of medications controlled under SDCL chapter 34-20 B shall be
				  witnessed by two persons, both of whom are a nurse or pharmacist, as designated
				  by facility policy. Methods of destruction or disposal may include:
(1) Disposal by using a professional waste
				hauler to take the medications to a permitted medical waste facility or by
				facility disposal at a permitted municipal solid waste landfill. Prior to
				disposal all medications shall be removed from original containers and made
				unpalatable by the addition of adulterants and alteration of solid dosage forms
				by dissolving or combination into a solid mass;
(2) Return to the dispensing pharmacy for
				destruction or dispose according to federal and state regulations;
(3) Return to an authorized reverse
				distributor company licensed by the South Dakota Board of Pharmacy;
				or
(4) Release to patient upon
				discharge after authorization by the patient's prescribing practitioner.
Documentation of destruction or disposal of medications shall
				  be included in the patient's record. The documentation shall include the method
				  of disposition (destruction, disposal, return to pharmacy, or release to
				  patient); the medication name, strength, prescription number (as applicable),
				  quantity, and date of disposition; and the name of any person who witnessed the
				  destruction or disposal.
Medications, excluding those controlled under SDCL chapter
				  34-20 B, contained in unit dose packaging meeting the requirements of §
										20:51:13:02.01 may be returned to
				  the dispensing pharmacy for credit and redispensing.
Any medication held for disposal shall be physically
				  separated from the medications being used in the facility, locked with access
				  limited, in an area with a system to reconcile, audit, or monitor them to
				  prevent diversion.
General Authority:
SDCL
					 34-12-13(9).
Law Implemented:
SDCL
					 34-12-13(9).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:08 - Medication Control › Section 44:75:08:07 - Medication administration

Current through Register Vol. 51, page 10, July 15, 2024
Each medication administered must be recorded in the
				  patient's medical record by the individual administering the medication.
				  Medication errors and drug reactions must be reported to the patient's
				  physician, physician assistant, or nurse practitioner and an entry made in the
				  patient's medical record. Orders involving abbreviations and chemical symbols
				  may be carried out only if the facility has a standard list of abbreviations
				  and symbols approved by the medical staff or, in the absence of an organized
				  medical staff, by the medical director. The facility must make the list
				  available to the nursing personnel. All medications must be administered to
				  patients by personnel acting under delegation of a licensed nurse, or licensed
				  to administer medications.
A person may not administer medications prepared by another
				  person, other than a pharmacist.
Medication administration shall comply with §§
									44:75:08:02 to
				  44:75:08:05, inclusive, and with
				  the requirements for training in §§20:48:04.01:14 and 20:48:04.01:15
				  and for supervision in § 20:48:04.01:02. The supervising nurse shall
				  provide an orientation to the unlicensed assistive personnel who will
				  administer medications. The orientation shall be specific to the facility and
				  relevant to the patients receiving administered medications.
General Authority:
SDCL
					 34-12-13(9).
Law Implemented:
SDCL
					 34-12-13(9).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:08 - Medication Control › Section 44:75:08:08 - Medication records

Current through Register Vol. 51, page 10, July 15, 2024
Medication administration records shall be used and regularly
				  checked against the practitioner's orders. Each medication administered must be
				  recorded in the patient's medical record and signed by the individual
				  administering the medication.
General Authority:
SDCL
					 34-12-13(9).
Law Implemented:
SDCL
					 34-12-13(9).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:08 - Medication Control › Section 44:75:08:09 - Administration of facility pharmacy

Current through Register Vol. 51, page 10, July 15, 2024
The pharmaceutical service of each facility with a licensed
				  full or part-time pharmacy shall be directed by a licensed pharmacist
				  accountable to the administration of the facility. Only prepackaged drugs or a
				  single dose unit may be removed from the pharmacy when the pharmacist is not
				  available. These drugs may be removed only by a designated registered nurse or
				  physician, physician assistant, or nurse practitioner in amounts sufficient
				  only for immediate therapeutic needs. A record of such withdrawals must be made
				  by the designated nurse or the physician, physician assistant, or nurse
				  practitioner making the withdrawal.
General Authority:
SDCL
					 34-12-13(9).
Law Implemented:
SDCL
					 34-12-13(9).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:09 - Medical record Services › Section 44:75:09:01 - Medical record department

Current through Register Vol. 51, page 10, July 15, 2024
Each facility shall have an organized medical record system.
				  A Each facility shall maintain a medical record for each level of care for each
				  patient admitted to the facility.
General Authority:
SDCL
					 34-12-13(10).
Law Implemented:
SDCL
					 34-12-13(10).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:09 - Medical record Services › Section 44:75:09:02 - Medical record department personnel

Current through Register Vol. 51, page 10, July 15, 2024
The Each facility shall have medical record functions
				  performed by personnel trained and equipped to facilitate the accurate
				  processing, checking, indexing, filing, and retrieval of all medical records.
				  The individual responsible for the medical records service must have knowledge
				  and training in the field of medical records.
General Authority:
SDCL
					 34-12-13(10).
Law Implemented:
SDCL
					 34-12-13(10).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:09 - Medical record Services › Section 44:75:09:03 - Written policies and confidentiality of records

Current through Register Vol. 51, page 10, July 15, 2024
Each facility shall have written policies and procedures to
				  govern the administration and activities of the medical record service that
				  address the confidentiality and safeguarding of medical records, the record
				  content, continuity of a patient's medical records during subsequent
				  admissions, requirements for completion of the record, and the entries to be
				  made by various authorized personnel.
General Authority:
SDCL
					 34-12-13(10).
Law Implemented:
SDCL
					 34-12-13(10).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:09 - Medical record Services › Section 44:75:09:04 - Record content

Current through Register Vol. 51, page 10, July 15, 2024
Each medical record shall show the condition of the patient
				  from the time of admission until discharge and shall 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)
				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, including practitioners, physical therapy, occupational therapy,
				and speech-language pathology;
(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, including the date, the time, and the action taken regarding
				each;
(11) A final diagnosis;
				and
(12) A discharge summary,
				including all discharge instructions for home care.
General Authority:
SDCL
					 34-12-13(10).
Law Implemented:
SDCL
					 34-12-13(10).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:09 - Medical record Services › Section 44:75:09:05 - Authentication

Current through Register Vol. 51, page 10, July 15, 2024
A facility shall ensure entries to the medical record are
				  signed or electronically authenticated. If the facility permits any portion of
				  the medical record to be generated by electronic or optical means, policies and
				  procedures shall exist to prohibit the use of authentication by unauthorized
				  users.
General Authority:
SDCL
					 34-12-13(10).
Law Implemented:
SDCL
					 34-12-13(10).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:09 - Medical record Services › Section 44:75:09:06 - Retention of medical records

Current through Register Vol. 51, page 10, July 15, 2024
A facility shall retain medical records for a minimum of ten
				  years from the actual visit date of service or patient care. The retention of
				  the record for ten years is not affected by additional and future visit dates.
				  Records of minors shall be retained until the minor reaches the age of majority
				  plus an additional two years, but no less than ten years from the actual visit
				  date of service or patient care.
General Authority:
SDCL
					 34-12-13(10).
Law Implemented:
SDCL
					 34-12-13(10).
Storage of medical records, §
											44:75:09:07.
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:09 - Medical record Services › Section 44:75:09:07 - Storage of medical records

Current through Register Vol. 51, page 10, July 15, 2024
A facility shall provide for filing, safe storage, and easy
				  accessibility of medical records. The medical records shall be preserved as
				  original records or in other readily retrievable and reproducible form. Medical
				  records shall be protected against access by unauthorized individuals. All
				  medical records must be retained by the health care facility upon change of
				  ownership.
General Authority:
SDCL
					 34-12-13(10).
Law Implemented:
SDCL
					 34-12-13(10).
Disposition of medical records on closure of facility or
					 transfer of ownership, §
											44:75:09:09.
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:09 - Medical record Services › Section 44:75:09:08 - Destruction of medical records

Current through Register Vol. 51, page 10, July 15, 2024
After the minimum retention period of ten years from the
				  actual visit date of care outlined in §
									44:75:09:06, the facility may, at
				  its discretion, destroy the medical record. Before the destruction of the
				  medical record, the facility shall prepare and retain a patient index or
				  abstract. The patient index or abstract shall include:
(1) Name;
(2) Medical record number;
(3) Date of birth;
(4) Summary of visit dates;
(5) Attending or admitting physician;
				and
(6) Diagnosis or diagnosis
				code.
The facility shall destroy the medical record in a way that
				  maintains confidentiality.
General Authority:
SDCL
					 34-12-13(10).
Law Implemented:
SDCL
					 34-12-13(10).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:09 - Medical record Services › Section 44:75:09:09 - Disposition of medical records on closure of facility or transfer of ownership

Current through Register Vol. 51, page 10, July 15, 2024
If a facility ceases operation, the facility shall provide
				  for safe storage and prompt retrieval of medical records and the patient
				  indexes specified in §
									44:75:09:08. The facility may
				  arrange storage of medical records with another facility of the same licensure
				  classification, transfer medical records to another health care provider at the
				  request of the patient or patient's legal representative, relinquish medical
				  records to the patient or patient's legal representative, or arrange storage of
				  remaining medical records with a third-party vendor who undertakes such a
				  storage activity. At least thirty days before closure, the facility shall
				  notify the department in writing indicating the provisions for the safe
				  preservation of medical records and their location and publish or share in the
				  nearest newspaper or the facility's website, the location and disposition
				  arrangements of the medical records.
If ownership of the facility is transferred, the new owner
				  shall maintain the medical records as if there was not a change in
				  ownership.
General Authority:
SDCL
					 34-12-13(10).
Law Implemented:
SDCL
					 34-12-13(10).
Storage of medical or care records, §
											44:75:09:07.
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:10 - Diagnostic services › Section 44:75:10:01 - Clinical laboratory services

Current through Register Vol. 51, page 10, July 15, 2024
Each hospital shall provide for emergency laboratory services
				  which are available twenty-four hours a day, seven days a week, including
				  holidays. Laboratory examinations necessary for diagnosis and treatment of the
				  patient shall be performed in the hospital or by arrangement. Laboratory
				  examinations required on admission to the hospital are determined by the
				  medical staff and bylaws. The original laboratory report shall be made a part
				  of the patient's medical record.
General Authority:
SDCL
					 34-12-13(11).
Law Implemented:
SDCL
					 34-12-13(11).
Note:
CLIA applications are obtained from the
					 South Dakota Department of Health, Office of Healthcare Facilities Licensure
					 and Certification, 600 East Capitol Avenue, Pierre, SD 57501. Telephone (605)
					 773-3356, or Division of Laboratory Standards and Performance, Health Standards
					 and Quality Bureau, Centers for Medicare/Medicaid Services, 7500 Security
					 Boulevard S- 2-11-07, Baltimore, MD 21244-1850. Telephone (410)-786-3531, or
					 online at
www.cms.gov/medicare/cms-forms/downloads//cms116/pdf
.
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:10 - Diagnostic services › Section 44:75:10:02 - Clinical pathology services

Current through Register Vol. 51, page 10, July 15, 2024
Each hospital laboratory shall have the services of a
				  pathologist available within the facility or by arrangement. The pathologist
				  shall examine tissues removed from hospital patients as outlined in hospital
				  policy. Pathology services shall be governed by written policies and procedures
				  establishing guidelines for the prompt transportation of specimens and
				  submission of reports.
General Authority:
SDCL
					 34-12-13(11).
Law Implemented:
SDCL
					 34-12-13(11).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:10 - Diagnostic services › Section 44:75:10:03 - Technical laboratory operations

Current through Register Vol. 51, page 10, July 15, 2024
Each hospital laboratory shall have a policy and procedural
				  manual for each phase of operation. There shall be a quality control program to
				  insure the reliability of laboratory test data. Each item of diagnostic test
				  equipment shall be routinely checked and shall be precise in terms of
				  calibration as shown by records maintained in the laboratory.
General Authority:
SDCL
					 34-12-13(11).
Law Implemented:
SDCL
					 34-12-13(11).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:10 - Diagnostic services › Section 44:75:10:04 - Blood transfusion services

Current through Register Vol. 51, page 10, July 15, 2024
Each facility providing transfusion services shall provide
				  facilities and equipment for the procurement, storage, and administration of
				  blood products. The transfusion service shall be under the supervision of the
				  medical staff. The medical staff or quality improvement committee shall review
				  all transfusions and transfusion reactions and make recommendations concerning
				  policies and procedures governing such practices.
General Authority:
SDCL
					 34-12-13(11).
Law Implemented:
SDCL
					 34-12-13(11).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:10 - Diagnostic services › Section 44:75:10:05 - Diagnostic x-ray services

Current through Register Vol. 51, page 10, July 15, 2024
Each hospital shall provide for emergency diagnostic x-ray
				  services which are available 24-hours a day, 7 days a week, including holidays,
				  except for specialized hospitals which can document to the satisfaction of the
				  department that this service is not essential to the specialty being served.
				  Safety and sanitation procedures as required by the department for the
				  radiological service which will protect the patient and the radiological worker
				  shall be established and enforced. There shall be a quality control program
				  with records maintained in the facility.
General Authority:
SDCL
					 34-12-13(11).
Law Implemented:
SDCL
					 34-12-13(11).
Radiation safety, art
					 44:03.
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:10 - Diagnostic services › Section 44:75:10:06 - Radiological service policies and manuals required

Current through Register Vol. 51, page 10, July 15, 2024
There shall be a policy and procedural manual for all phases
				  of the radiological services. If radioactive isotopes are to be used within the
				  facility, policies which are approved by the medical staff shall be
				  established.
General Authority:
SDCL
					 34-12-13(11).
Law Implemented:
SDCL
					 34-12-13(11).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:10 - Diagnostic services › Section 44:75:10:07 - Radiological department personnel

Current through Register Vol. 51, page 10, July 15, 2024
There shall be trained personnel to provide the scope of
				  services offered by the facility. If therapeutic radiological services are
				  provided, the services shall be under the direct supervision of a
				  radiologist.
General Authority:
SDCL
					 34-12-13(11).
Law Implemented:
SDCL
					 34-12-13(11).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:10 - Diagnostic services › Section 44:75:10:08 - Radiological reports

Current through Register Vol. 51, page 10, July 15, 2024
Complete signed reports of the interpretations of all
				  radiological examinations made by practitioners shall be made a part of the
				  patient's clinical record. The radiological department shall have a policy that
				  requires any record to be retained for at least ten years and any film to be
				  retained for at least five years.
General Authority:
SDCL
					 34-12-13(10).
Law Implemented:
SDCL
					 34-12-13(10).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:11 - Hospital complementary services › Section 44:75:11:01 - Surgical services

Current through Register Vol. 51, page 10, July 15, 2024
Each hospital in which surgery is performed shall maintain an
				  operating suite with appropriate equipment, including X-ray viewing devices.
				  The suite shall be supervised by a registered nurse with training and
				  experience in operating room services. A circulating nurse shall be assigned to
				  each operating or procedure room during each procedure and shall be present for
				  the duration of the surgical procedure unless it becomes necessary for the
				  nurse to leave the operating or procedure room as part of the procedure or the
				  nurse is relieved by another circulating nurse. A facility shall develop and
				  implement written policies and procedures for surgical services which govern
				  surgical personnel privileges, supportive services of other professional and
				  perioperative personnel, and operating suite procedures. A facility shall
				  develop, implement, and post policies and procedures pertaining to safety
				  controls shall be developed and implemented. Each facility shall maintain a
				  roster of surgical staff members which delineates the surgical privileges of
				  each member in the operating suite.
General Authority:
SDCL
					 34-12-13(12).
Law Implemented:
SDCL
					 34-12-13(12).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:11 - Hospital complementary services › Section 44:75:11:02 - Surgical records

Current through Register Vol. 51, page 10, July 15, 2024
When surgery is performed, the following record requirements
				  apply:
(1) An operating room register
				shall be complete and up to date. It shall 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, including
				at least a medical history, a copy of the physician's examination, copies of
				laboratory tests, a signed consent for the surgical procedure to be performed,
				and a preoperative diagnosis, shall be made available in the surgical suite at
				the time of surgery; and
(3) An
				accurate and complete description of the operative procedure shall be recorded
				by the operating surgeon within forty-eight hours following completion of
				surgery.
General Authority:
SDCL
					 34-12-13(10)(12).
Law Implemented:
SDCL
					 34-12-13(10)(12).
South Dakota Administrative Rules › Title 44 - Department of Health › Article 44:75 - Hospital, specialized Hospital critical access Hospital, and rural emergency Hospital facilities › Chapter 44:75:11 - Hospital complementary services › Section 44:75:11:03 - Obstetric and newborn services

Current through Register Vol. 51, page 10, July 15, 2024
Each hospital offering obstetric and newborn services shall
				  maintain facilities, equipment, and supplies appropriate to the service. The
				  hospital shall establish, implement, and maintain written policies and
				  procedures and have techniques and methods that will provide safe intrapartum
				  and postpartum care on the nursing unit for obstetric patients, immediate
				  delivery room care, recovery period care, and continuing nursery care for the
				  newborn infants. A medical record for each obstetrical patient and newborn
				  infant, and a delivery room register shall be maintained.
General Authority:
SDCL
					 34-12-13(12).
Law Implemented:
SDCL
					 34-12-13(12).