Current through Register Vol. 30, No. 44, November 1, 2024
Section R9-10-1807 - Medical RecordsA. A provider shall ensure that: 1. A medical record is established and maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1;2. An entry in a resident's medical record is: a. Only recorded by the provider or individual designated by the provider to record an entry;b. Dated, legible, and authenticated; andc. Not changed to make the initial entry illegible;3. A resident's medical record is available to an individual: a. Authorized by policies and procedures to access the resident's medical record;b. If the individual is not authorized according to policies and procedures, with the written consent of the resident or the resident's representative; orc. As permitted by law; and4. A resident's medical record is protected from loss, damage, or unauthorized use.B. If a provider maintains residents' medical records electronically, the provider shall ensure that safeguards exist to prevent unauthorized access.C. A provider shall ensure that a resident's medical record contains: 1. Resident information that includes: b. The resident's date of birth,c. Any known allergies, andd. Medication information for the resident;2. The names, addresses, and telephone numbers of: a. The resident's medical practitioner;b. The resident's case manager, if applicable;c. The behavioral health professional assigned to the resident by the adult behavioral health therapeutic home's collaborating health care institution; andd. An individual to be contacted in the event of an emergency;3. The date of the resident's acceptance by the adult behavioral health therapeutic home and, if applicable, the date of the resident's release from the adult behavioral health therapeutic home;4. If applicable, the name and contact information of the resident's representative and: a. The document signed by the resident consenting for the resident's representative to act on the resident's behalf; orb. If the resident's representative: i. Has a health care power of attorney established under A.R.S. § 36-3221 or a mental health care power of attorney executed under A.R.S. § 36-3282, a copy of the health care power of attorney or mental health care power of attorney; orii. Is a legal guardian, a copy of the court order establishing guardianship;5. A copy of the resident's treatment plan and any updates to the resident's treatment plan, obtained from the adult behavioral health therapeutic home's collaborating health care institution;6. For a resident receiving assistance in the self-administration of medication, documentation that includes for each medication: a. The date and time of assistance;b. The name, strength, dosage, and route of administration;c. The provider's signature or first and last initials; andd. Any adverse reaction the resident has to the medication;7. Documentation of the resident's refusal of a medication, if applicable;8. Documentation of any significant change in a resident's behavior or physical, cognitive, or functional condition and the action taken by a provider to address the resident's changing needs;9. If applicable, documentation of any actions taken to control the resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual; and10. If applicable, a written notice of termination of residency.Ariz. Admin. Code § R9-10-1807
New Section made by exempt rulemaking at 20 A.A.R. 1409, effective 7/1/2014.