Ariz. Admin. Code § 9-10-712

Current through Register Vol. 30, No. 45, November 8, 2024

Section R9-10-712 - Medical Records

A. An administrator 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. 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 resident's medical record and includes the time of the order;

b. Authenticated by a medical practitioner or behavioral health professional according to policies and procedures; and

c. If the order is a verbal order, authenticated by the medical practitioner or behavioral health professional 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 resident's medical record is available to an individual:

a. Authorized according to 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; or

c. As permitted by law;

6. Policies and procedures include the maximum time-frame to retrieve a resident's medical record at the request of a medical practitioner, behavioral health professional, or authorized personnel member; and

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

B. If a behavioral health residential facility maintains residents' 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 resident's medical record is recorded by the computer's internal clock.

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

1. Resident information that includes:

a. The resident's name;

b. The resident's address;

c. The resident's date of birth; and

d. Any known allergies, including medication allergies;

2. The name of the admitting medical practitioner or behavioral health professional;

3. An admitting diagnosis or presenting behavioral health issues;

4. The date of admission and, if applicable, date of discharge;

5. If applicable, the name and contact information of the resident's representative and:

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

b. 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; or

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

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

7. Documentation of medical history and results of a physical examination;

8. A copy of resident's health care directive, if applicable;

9. Orders;

10. If applicable, documentation that evaluation or treatment was ordered by a court according to A.R.S. Title 36, Chapter 5 or A.R.S. § 8-341.01;

11. Assessment;

12. Treatment plans;

13. Interval notes;

14. Progress notes;

15. Documentation of behavioral health services and physical health services provided to the resident;

16. If applicable, documentation of the use of an emergency safety response;

17. If applicable, documentation of time-out required in R9-10-714(6);

18. Except as allowed in R9-10-707(E)(1)(d), documentation of freedom from infectious tuberculosis required in R9-10-707(A)(13);

19. The disposition of the resident after discharge;

20. The discharge plan;

21. The discharge summary, if applicable;

22. If applicable:

a. Laboratory reports,

b. Radiologic reports,

c. Diagnostic reports, and

d. Consultation reports; and

23. Documentation of medication administered to the resident 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 administered initially or on a PRN basis:

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

ii. The effect of the medication administered;

d. For a psychotropic medication, when administered initially or on a PRN basis:

i. An assessment of the resident'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 or providing assistance in the self-administration of the medication; and

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

Ariz. Admin. Code § R9-10-712

Adopted 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). Section repealed; 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. Amended by final rulemaking at 25 A.A.R. 1583, effective 10/1/2019. Amended by final expedited rulemaking at 26 A.A.R. 551, effective 3/3/2020.

The following Section was adopted 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 these rules (Supp. 98-4).