Ariz. Admin. Code § 9-10-1908

Current through Register Vol. 30, No. 50, December 13, 2024
Section R9-10-1908 - 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 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 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 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; and
6. A patient's medical record is protected from loss, damage, or unauthorized use.
B.If a counseling facility 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 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 and address, and
b. The patient's date of birth;
2. A diagnosis or reason for counseling;
3. Documentation of general consent and, if applicable, informed consent for counseling by the patient or the patient's representative;
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. 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;
5. Documentation of medical history;
6. Orders;
7. Assessment;
8. Interval notes;
9. Progress notes;
10. Documentation of counseling provided to the patient;
11. The name of each individual providing counseling;
12. Disposition of the patient upon discharge;
13. Documentation of the patient's follow-up instructions provided to the patient;
14. A discharge summary; and
15. 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.

Ariz. Admin. Code § R9-10-1908

Adopted by exempt rulemaking at 20 A.A.R. 3535, effective 1/1/2015.