Ariz. Admin. Code § 9-10-611

Current through Register Vol. 30, No. 50, December 13, 2024

Section R9-10-611 - 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 a personnel member 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 practitioner according to policies and procedures; and

c. If the order is a verbal order, authenticated by the medical practitioner 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 e signature represents is accountable for the use of the rubber-stamp signature or electronic e signature;

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

a. Authorized according to 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 a patient or the patient's representative; or

c. As permitted by law; and

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

B. If a hospice 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 telephone number,

d. The patient's date of birth, and

e. Any known allergy;

2. The admission date and, if applicable, the date that the patient stopped receiving services from the hospice;

3. The name and telephone number of the patient's physician;

4. 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;

5. The admitting diagnosis;

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

7. Documentation of medical history;

8. A copy of the patient's living will, health care power of attorney, or other health care directive, if applicable;

9. Orders;

10. The assessment required in R9-10-607(B)(1);

11. Care plans;

12. Progress notes for each patient contact, including:

a. The date of the patient contact,

b. The services provided,

c. A description of the patient's condition, and

d. Instructions given to the patient or patient's representative;

13. Documentation of hospice services provided to the patient;

14. 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;

15. Documentation of coordination of patient care;

16. Documentation of contacts with the patient's physician by a personnel member;

17. The discharge summary, if applicable;

18. If applicable, transfer documentation from a sending health care institution; and

19. 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, when initially administered or when administered 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, when initially administered or when 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 identification, signature, and professional designation of the individual administering the medication; and

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

Ariz. Admin. Code § R9-10-611

Adopted effective November 6, 1978 (Supp. 78-6). Section R9-10-611 repealed effective November 1, 1998, under an exemption from the provisions of the Administrative Procedure Act pursuant to Laws 1998, Ch. 178, § 17; filed with the Office of the Secretary of State October 2, 1998 (Supp. 98-4). New Section made by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). . Amended by exempt rulemaking at 20 A.A.R. 1409, effective 7/1/2014.

The following Section was repealed under an exemption from the provisions of the Administrative Procedure Act which means these rules were not reviewed by the Governor's Regulatory Review Council; the Department did not submit notice of proposed rulemaking to the Secretary of State for publication in the Arizona Administrative Register; and the Department was not required to hold public hearings on the repealing of these rules.