Ariz. Admin. Code § 9-10-712

Current through Register Vol. 30, No. 50, December 13, 2024
Section R9-10-712 - 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 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 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 according to policies and procedures to access the resident's medical record;
b. If the individual is not authorized according to policies and procedures, with the written consent of the resident or the resident's representative; or
c. As permitted by law;
6. Policies and procedures include the maximum time-frame to retrieve a resident's medical record at the request of a medical practitioner, behavioral health professional, or authorized personnel member; and
7. A resident's medical record is protected from loss, damage, or unauthorized use.
B. If a behavioral health residential facility 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 address;
c. The resident's date of birth; and
d. Any known allergies, including medication allergies;
2. The name of the admitting medical practitioner or behavioral health professional;
3. An admitting diagnosis or presenting behavioral health issues;
4. The date of admission and, if applicable, date of discharge;
5. If applicable, the name and contact information of the resident's representative and:
a. If the resident is 18 years of age or older or an emancipated minor, 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. If applicable, documented general consent and informed consent for treatment by the resident or the resident's representative;
7. Documentation of medical history and results of a physical examination;
8. A copy of resident's health care directive, if applicable;
9. Orders;
10. If applicable, documentation that evaluation or treatment was ordered by a court according to A.R.S. Title 36, Chapter 5 or A.R.S. § 8-341.01;
11. Assessment;
12. Treatment plans;
13. Interval notes;
14. Progress notes;
15. Documentation of behavioral health services and physical health services provided to the resident;
16. If applicable, documentation of the use of an emergency safety response;
17. If applicable, documentation of time-out required in R9-10-714(6);
18. Except as allowed in R9-10-707(E)(1)(d), documentation of freedom from infectious tuberculosis required in R9-10-707(A)(13);
19. The disposition of the resident after discharge;
20. The discharge plan;
21. The discharge summary, if applicable;
22. If applicable:
a. Laboratory reports,
b. Radiologic reports,
c. Diagnostic reports, and
d. Consultation reports; and
23. Documentation of medication administered to the resident that includes:
a. The date and time of administration;
b. The name, strength, dosage, and route of administration;
c. For a medication administered for pain, when administered initially or on a PRN basis:
i. An assessment of the resident's pain before administering the medication, and
ii. The effect of the medication administered;
d. For a psychotropic medication, when administered initially or on a PRN basis:
i. An assessment of the resident's behavior before administering the psychotropic medication, and
ii. The effect of the psychotropic medication administered;
e. The identification, signature, and professional designation of the individual administering or providing assistance in the self-administration of the medication; and
f. Any adverse reaction a resident has to the medication.

Ariz. Admin. Code § R9-10-712

Adopted effective November 1, 1998, under an exemption from the provisions of the Administrative Procedure Act pursuant to Laws 1998, Ch. 178, §17; filed with the Office of the Secretary of State October 2, 1998 (Supp. 98-4). 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. Amended by final rulemaking at 25 A.A.R. 1583, effective 10/1/2019. Amended by final expedited rulemaking at 26 A.A.R. 551, effective 3/3/2020.

The following Section was adopted under an exemption from the provisions of the Administrative Procedure Act which means these rules were not reviewed by the Governor's Regulatory Review Council; the Department did not submit notice of proposed rulemaking to the Secretary of State for publication in the Arizona Administrative Register; and the Department was not required to hold public hearings on these rules (Supp. 98-4).