Ariz. Admin. Code § 9-10-2111

Current through Register Vol. 30, No. 44, November 1, 2024

Section R9-10-2111 - Medical Records

A. An administrator shall ensure that:

1. A patient's medical record is established and maintained for each patient according to A.R.S. Title 12, Chapter 13, Article 7.1;

2. An entry in a patient's medical record is:

a. Recorded only by an individual authorized by policies and procedures to make the entry;

b. Dated, legible, and authenticated; and

c. Not changed to make the initial entry illegible;

3. An order is:

a. Dated when the order is entered in the patient's medical record and includes the time of the order;

b. Authenticated by a medical staff according to policies and procedures; and

c. If the order is a verbal order, authenticated by the medical staff issuing the order;

4. If a rubber-stamp signature or an electronic signature is used to authenticate an order, the individual whose signature the rubber-stamp signature or electronic signature represents is accountable for the use of the rubber-stamp signature or electronic signature;

5. A patient's medical record is available to an individual:

a. Authorized according by policies and procedures to access the patient's medical record;

b. If the individual is not authorized according to policies and procedures, with the written consent of the patient or the patient's representative; or

c. As permitted by law;

6. Policies and procedures that include the maximum time-frame to retrieve an onsite or off-site patient's medical record at the request of a medical staff or authorized personnel member; and

7. A patient's medical record is protected from loss, damage, or unauthorized use.

B. If a recovery care center maintains patients' medical records electronically, an administrator shall ensure that:

1. Safeguards exist to prevent unauthorized access, and

2. The date and time of an entry in a patient's medical record is recorded by the computer's internal clock.

C. An administrator shall ensure that a patient's medical record contains:

1. Patient information that includes:

a. The patient's name,

b. The patient's address,

c. The patient's date of birth, and

d. Any known allergies;

2. The date of admission and, if applicable, the date of discharge;

3. The admitting diagnosis;

4. A discharge summary from the referring health care institution or physician;

5. If applicable, documented general consent and informed consent by the patient or the patient's representative;

6. The medical history and physical examination required in R9-10-2107(B)(1);

7. A copy of the patient's health care directive, if applicable;

8. The name and telephone number of the patient's medical practitioner;

9. If applicable, the name and contact information of the patient's representative and:

a. If the patient is 18 years of age or older or an emancipated minor, the document signed by the patient consenting for the patient's representative to act on the patient's behalf; or

b. If the patient's representative;

i. Is a legal guardian, a copy of the court order establishing guardianship; or

ii. 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;

10. Orders;

11. Nursing assessment;

12. Treatment plans;

13. Progress notes;

14. Documentation of recovery care center services provided to a patient;

15. The disposition of the patient after discharge;

16. The discharge plan;

17. A discharge summary, if applicable;

18. Transfer documentation from the referring health care institution or physician;

19. If applicable:

a. A laboratory report,

b. A radiologic report,

c. A diagnostic report, and

d. A consultation report;

20. If applicable, documentation of any actions taken to control the patient's sudden, intense, or out-of-control behavior to prevent harm to the patient or another individual;

21. If applicable, documentation that evacuation from the recovery care center would cause harm to the patient; and

22. Documentation of a medication administered to the patient that includes:

a. The date and time of administration;

b. The name, strength, dosage, and route of administration;

c. For a medication administered for pain on a PRN basis:

i. An assessment of the patient's pain before administering the medication, and

ii. The effect of the medication administered;

d. For a psychotropic medication administered on a PRN basis:

i. An assessment of the patient's behavior before administering the psychotropic medication, and

ii. The effect of the psychotropic medication administered;

e. The signature of the individual administering or observing the patient self-administer the medication; and

f. Any adverse reaction a patient has to the medication.

D. An administrator shall ensure that a patient's medical record is completed within 30 calendar days after the patient's discharge.

Ariz. Admin. Code § R9-10-2111

Renumbered from R9-10-511 by final rulemaking at 25 A.A.R. 1222, effective 4/25/2019