Ariz. Admin. Code § 9-10-411

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

Section R9-10-411 - 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 an individual 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 to access the resident's medial record according to policies and procedures;

b. If the individual is not authorized to access the resident's medical record according to policies and procedures, with the written consent of the resident or the resident's representative; or

c. As permitted by law; and

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

B. If a nursing care institution 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 date of birth; and

c. Any known allergies, including medication allergies;

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

3. The admitting diagnosis or presenting symptoms;

4. Documentation of general consent and, if applicable, informed consent;

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

a. 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. The medical history and physical examination required in R9-10-407(6);

7. A copy of the resident's living will or other health care directive, if applicable;

8. The name and telephone number of the resident's attending physician;

9. Orders;

10. Care plans;

11. Behavioral care plans, if the resident is receiving behavioral care;

12. Documentation of nursing care institution services provided to the resident;

13. Progress notes;

14. If applicable, documentation of any actions taken to control the resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;

15. If applicable, documentation that evacuation from the nursing care institution would cause harm to the resident;

16. The disposition of the resident after discharge;

17. The discharge plan;

18. The discharge summary;

19. Transfer documentation;

20. If applicable:

a. A laboratory report,

b. A radiologic report,

c. A diagnostic report, and

d. A consultation report;

21. Documentation of freedom from infectious tuberculosis required in R9-10-407(7);

22. Documentation of a medication administered to the resident that includes:

a. The date and time of administration;

b. The name, strength, dosage, and route of administration;

c. The type of vaccine, if applicable;

d. For a medication administered for pain on a PRN basis:

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

ii. The effect of the medication administered;

e. For a psychotropic medication administered on a PRN basis:

i. An evaluation of the resident's symptoms before administering the psychotropic medication, and

ii. The effect of the psychotropic medication administered;

f. The identification, signature, and professional designation of the individual administering the medication; and

g. Any adverse reaction a resident has to the medication;

23. If the resident has been assessed for receiving nutrition and feeding assistance from a nutrition and feeding assistant, documentation of the assessment and the determination of eligibility; and

24. If applicable, a copy of written notices, including follow-up instructions, provided to the resident or the resident's representative.

Ariz. Admin. Code § R9-10-411

Adopted effective January 28, 1980 (Supp. 80-1). Section repealed by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). New Section R9-10-411 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.