Ariz. Admin. Code § 9-10-910

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

Section R9-10-910 - Medical Records

A. An administrator shall ensure that:

1. A medical record is established and maintained for a 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 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 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 the medical staff member 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 patient's medical record is available to an individual:

a. Authorized according to policies and procedures to access the patient's medical record;

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

c. As permitted by law; and

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

B. If an outpatient surgical center 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 patient's medical record 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 allergies, including medication allergies;

2. The admitting medical practitioner;

3. An admitting diagnosis;

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

5. 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;

6. The date of admission and, if applicable, date of discharge;

7. Documentation of medical history and results of a physical examination;

8. A copy of patient's health care directive, if applicable;

9. Orders;

10. Progress notes;

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

12. Documentation of outpatient surgical center services provided to the patient;

13. A discharge summary, if applicable;

14. Documentation of receipt of written discharge instructions by the patient or patient's representative;

15. If applicable:

a. Laboratory reports,

b. Radiologic report, and

c. Diagnostic reports;

16. The anesthesia report, required in R9-10-911(C)(2);

17. The operative report of the surgical procedure, required in R9-10-911(C)(1); and

18. Documentation of a medication administered to the patient 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:

i. An assessment of the patient's pain before administering the medication, and

ii. The effect of the medication administered;

d. For a psychotropic medication:

i. An assessment of the patient'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 observing the self-administration of the medication; and

f. Any adverse reaction a patient has to the medication.

Ariz. Admin. Code § R9-10-910

Adopted effective February 17, 1995 (Supp. 95-1). Section repealed; new Section made by final rulemaking at 9 A.A.R. 338, effective March 16, 2003 (Supp. 03-1). 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.