Ariz. Admin. Code § 9-10-213

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

Section R9-10-213 - 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 staff member according to policies and procedures; and

c. If the order is a verbal order, authenticated by a medical staff member or medical practitioner ;

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 personnel members and medical staff members authorized by policies and procedures to access the medical record;

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

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

B. If a hospital 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 medical record for an inpatient 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 allergy, including medication allergies or sensitivities;

2. Medication information that includes:

a. A medication ordered for the patient; and

b. A medication administered to the patient including:

i. The date and time of administration;

ii. The name, strength, dosage, amount, and route of administration;

iii. The identification and authentication of the individual administering the medication; and

iv. Any adverse reaction the patient has to the medication;

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

4. A medical history and results of a physical examination or an interval note;

5. If the patient provides a health care directive, the health care directive signed by the patient;

6. An admitting diagnosis;

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

8. Names of the admitting medical staff member and medical practitioners coordinating the patient's care;

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. 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;

10. Orders;

11. Care plans;

12. Documentation of hospital services provided to the patient;

13. Progress notes;

14. The disposition of the patient after discharge;

15. Discharge planning, including discharge instructions required in R9-10-209(B)(3);

16. A discharge summary; and

17. If applicable:

a. A laboratory report,

b. A pathology report,

c. An autopsy report,

d. A radiologic report,

e. A diagnostic imaging report,

f. Documentation of restraint or seclusion, and

g. A consultation report.

D. An administrator shall ensure that a hospital's medical record for an outpatient contains:

1. Patient information that includes:

a. The patient's name;

b. The patient's address;

c. The patient's date of birth;

d. The name and contact information of the patient's representative, if applicable; and

e. Any known allergy including medication allergies or sensitivities;

2. If necessary for treatment, medication information that includes:

a. A medication ordered for the patient; and

b. A medication administered to the patient including:

i. The date and time of administration;

ii. The name, strength, dosage, amount, and route of administration;

iii. The identification and authentication of the individual administering the medication; and

iv. Any adverse reaction the patient has to the medication;

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

4. An admitting diagnosis or reason for outpatient medical services;

5. Orders;

6. Documentation of hospital services provided to the patient; and

7. If applicable:

a. A laboratory report,

b. A pathology report,

c. An autopsy report,

d. A radiologic report,

e. A diagnostic imaging report,

f. Documentation of restraint or seclusion, and

g. A consultation report.

E. In addition to the requirements in subsection (D), an administrator shall ensure that the hospital's record of emergency services provided to a patient contains:

1. Documentation of treatment the patient received before arrival at the hospital, if available;

2. The patient's medical history;

3. An assessment, including the name of the individual performing the assessment;

4. The patient's chief complaint;

5. The name of the individual who treated the patient in the emergency room, if applicable; and

6. The disposition of the patient after discharge.

Ariz. Admin. Code § R9-10-213

Former Section R9-10-213 renumbered as R9-10-313 as an emergency effective February 23, 1979, new Section R9-10-213 adopted effective February 23, 1979 (Supp. 79-1). Section repealed; new Section made by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). Amended by final rulemaking at 11 A.A.R. 536, effective March 5, 2005 (Supp. 05-1). Section R9-10-213 renumbered to R9-10-211; new Section R9-10-213 renumbered from R9-10-228 and amended 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.