Ariz. Admin. Code § 9-10-1312

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

Section R9-10-1312 - Medical Records

A. An administrator shall ensure that:

1. A 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 facility 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 or behavioral health professional according to facility 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 the electronic 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 the patient or the patient's representative; or

c. As permitted by law;

6. A patient's medical record is available to the patient or patient's representative upon request at a time agreed upon by the patient or patient's representative and the administrator; and

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

B. If a behavioral health specialized transitional facility maintains patient's 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. A copy of the court order requiring the patient to be detained at or committed to the behavioral health specialized transitional facility;

2. The date the patient was detained at or committed to the behavioral health specialized transitional facility;

3. 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, including medication allergies;

4. Documentation of the patient's freedom from infectious tuberculosis as required in R9-10-1306(C)(2);

5. Documentation of general consent and, if applicable, informed consent for treatment by the patient or the patient's representative, except in an emergency;

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

a. 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;

7. Documentation of medical history and physical examination of the patient;

8. A copy of patient's health care directives, if applicable;

9. Orders;

10. The patient's assessment including updates;

11. The patient's treatment plan including updates;

12. Progress notes;

13. Documentation of transportation provided to the patient;

14. Documentation of behavioral health services and physical health services provided to the patient;

15. Documentation of patient's annual examination and report required by A.R.S. § 36-3708;

16. Documentation of the annual written notice of the patient of the patient's right to petition for:

a. Conditional release to a less restrictive alternative as required by A.R.S. § 36-3709, or

b. Discharged as required by A.R.S. § 36-3714;

17. A copy of any petition for discharge or conditional release to a less restrictive alternative filed by the patient and provided to the behavioral health specialized transitional facility and the outcome of the petition;

18. Documentation of the patient's, if applicable;

a. Conditional release to a less restrictive alternative; or

b. Discharge, including the disposition of the patient upon discharge;

19. If a patient has been discharged, a discharge summary that includes:

a. A summary of the treatment provided to the patient;

b. The patient's progress in meeting treatment goals, including treatment goals that were and were not achieved;

c. The name, dosage, and frequency of each medication for the patient ordered at the time of the patient's discharge from the behavioral health specialized transitional facility;

d. A description of the disposition of the patient's possessions, funds, or medications; and

e. The date the patient was discharged from the behavioral health specialized transitional facility;

20. If applicable:

a. Laboratory reports,

b. Radiologic reports,

c. Diagnostic reports,

d. Documentation of restraint or seclusion,

e. Patient follow-up instructions, and

f. Consultation reports; and

21. 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:

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:

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 or observing the self-administration of the medication;

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

g. If applicable, a patient's refusal to take medication ordered for the patient.

Ariz. Admin. Code § R9-10-1312

Emergency rule adopted effective November 29, 1991, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 91-4). Emergency rule adopted again effective February 28, 1992, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 92-1). Emergency rule adopted again effective May 28, 1992, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 92-2). Emergency rule adopted again effective August 27, 1992, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 92-3). Adopted with changes effective November 25, 1992 (Supp. 92-4). Section R9-10-1312 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. Amended by final expedited rulemaking at 24 A.A.R. 2764, effective 9/11/2018.

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.