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The South Dakota Sunshine Law is a series of laws designed to guarantee that public has access to public records of governmental bodies. Public records are defined as all records kept by public bodies in South Dakota, no matter the physical form.
Authentication. confirms the content and accuracy of the entry into the medical record by written signature, initials, or computer-generated signature code.
The Data Protection Act 1998 gives every living person (or authorised representative) the right to apply for access to their health records.
Authentication of medical record entries may include written signatures, initials, computer key, or other code. For authentication, in written or electronic form, a method must be established to identify the author.
§482.24(c)(1) -- All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. All entries in the medical record must be legible.
Retention of medical records. A facility shall retain medical records for a minimum of ten years from the actual visit date of service or resident care. The retention of the record for ten years is not affected by additional and future visit dates.
To summarize, first, as to records: The records have to be authenticated by offering evidence that they were prepared by agents of the medical facility in the ordinary course of business at or near the time of the relevant act, condition or event contained in the records, and that the mode of preparation indicate the ...
The reasons for and results of x-rays, lab tests, and other services should be documented or included in the medical record. Relevant health risk factors should be identified. The patient's progress, including treatment, change in treatment, change in diagnosis and patient non-compliance should be documented.