Ariz. Admin. Code § 9-10-512

Current through Register Vol. 30, No. 45, November 8, 2024

Section R9-10-512 - 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 an ICF/IID 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 the resident's placement evaluation;

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

6. 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;

7. The name and contact information of an individual to be contacted under R9-10-503(I);

8. Documentation of the initial assessment required in R9-10-507(3) to determine acuity;

9. The medical history and physical examination required in R9-10-516(A)(4);

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

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

12. Orders;

13. Documentation of the resident's comprehensive assessment;

14. Individual program plans, including nursing care plans or medical care plans, if applicable;

15. Documentation of active treatment and other physical health services or behavioral care provided to the resident;

16. Progress notes, including data needed to evaluate the effectiveness of the methods, schedule, and strategies being used to accomplish the goals in the resident's individual program plan;

17. If applicable, documentation of restraint or seclusion;

18. If applicable, documentation of any actions other than restraint or seclusion taken to control or address the resident's behavior to prevent harm to the resident or another individual or to improve the resident's social interactions;

19. If applicable, documentation that evacuation from the ICF/IID would cause harm to the resident;

20. The disposition of the resident after discharge;

21. The discharge plan;

22. The discharge summary;

23. Transfer documentation;

24. If applicable:

a. A laboratory report,

b. A radiologic report,

c. A diagnostic report, and

d. A consultation report;

25. Documentation of freedom from infectious tuberculosis required in R9-10-507(10);

26. 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; and

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

Ariz. Admin. Code § R9-10-512

Adopted as an emergency effective October 26, 1988, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 88-4). Emergency expired. Readopted without change as an emergency effective January 27, 1989, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 89-1). Emergency expired. Readopted without change as an emergency effective April 27, 1989, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 89-2). Emergency expired. Readopted without change as an emergency effective July 31, 1989, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 89-3). Permanent rules adopted with changes effective October 30, 1989 (Supp. 89-4). Section repealed, new Section adopted effective April 4, 1994 (Supp. 94-2). Section repealed; 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. Adopted by final rulemaking at 25 A.A.R. 1222, effective 4/25/2019. Amended by exempt rulemaking at 26 A.A.R. 72, effective 1/1/2020.