Ariz. Admin. Code § 9-10-2008

Current through Register Vol. 30, No. 49, December 6, 2024

Section R9-10-2008 - Medical Records

A. A medical director shall ensure that a medical record is established and maintained for a patient that contains:

1. Patient identification, including:

a. The patient's name, address, and date of birth;

b. The patient's representative, if applicable; and

c. The name and telephone number of an individual to contact in an emergency;

2. The patient's medical history;

3. The patient's physical examination;

4. Laboratory test results;

5. The patient's diagnosis, including co-occurring disorders;

6. The patient's treatment plan;

7. If applicable:

a. The effectiveness of the patient's current treatment,

b. The duration of the current treatment,

c. Alternative treatments tried by or planned for the patient, and

d. The expected benefit of a new treatment compared with continuing the current treatment;

8. Each consent form signed by the patient or the patient's representative;

9. The patient's medication information, including:

a. The patient's age and weight;

b. The medications and herbal supplements the patient is currently taking; and

c. Allergies or sensitivities to medications, antiseptic solutions, or latex;

10. Prescriptions ordered for the patient and, if an opioid is prescribed or ordered:

a. The nature and intensity of the patient's pain,

b. The specific opioid and the reason for the prescription or order,

c. The objectives used to determine whether the patient is being successfully treated, and

d. Other factors relevant to prescribing or ordering an opioid for the patient;

11. Medications administered to the patient and, if an opioid is administrated:

a. The patient's need for the opioid before the opioid was administered, and

b. The effect of the opioid administered; and

12. A record of services provided to the patient.

B. A licensee shall ensure that:

1. A medical record is accessible only to the Department or personnel members authorized by policies and procedures;

2. Medical record information is confidential and released only with the written informed consent of a patient or the patient's representative or as otherwise permitted by law; and

3. A medical record is protected from loss, damage, or unauthorized use and is retained according to A.R.S. § 12-2297.

C. A medical director shall ensure that:

1. Only personnel authorized by policies and procedures record or sign an entry in a medical record;

2. An entry in a medical record is dated and legible;

3. An entry is authenticated;

4. An entry is not changed after it has been recorded, but additional information related to an entry may be recorded in the medical record;

5. When a verbal or telephone order is entered in the medical record, the entry is authenticated according to policies and procedures by the individual who issued the order;

6. If a rubber-stamp signature or an electronic signature is used:

a. An individual's rubber-stamp or electronic signature is not used by another individual; and

b. 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; and

7. If a pain management clinic maintains medical records electronically, the date and time of an entry is recorded by the computer's internal clock.

Ariz. Admin. Code § R9-10-2008

Adopted by final rulemaking at 24 A.A.R. 3020, effective 1/1/2019.