Ariz. Admin. Code § R9-10-1209 - Medical Records

A. An administrator shall ensure that:

1. A medical record is established and maintained for each 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 a 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 physician, registered nurse practitioner, or podiatrist according to policies and procedures; and

c. If the order is a verbal order, authenticated by the physician, registered nurse practitioner, or podiatrist 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 personnel members, physicians, registered nurse practitioners, or podiatrists authorized by policies and procedures to access the patient's medical record;

6. Information in a patient's medical record is disclosed to an individual not authorized under subsection (A)(5) only with the written consent of a patient or the patient's representative or as permitted by law; and

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

B. If a home health agency 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 and telephone number;

c. The patient's date of birth; and

d. The name and contact information of the patient's representative, if applicable; and

e. d. Any known allergies, including medication allergies;

2. The date the patient began receiving services from the home health agency and, if applicable, the date the patient stopped receiving services from the home health agency;

3. The name and telephone of the patient's physician or registered nurse practitioner;

4. The name and telephone number of patient's podiatrist, if applicable;

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

6. Documentation of medical history and current diagnoses;

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

8. 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. Is a legal guardian, a copy of the court order establishing guardianship; or

ii. 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;

8. 9. Orders;

9. 10. Assessments;

10. 11. Care plan;

11. 12. Progress notes;

13. 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. 14. Documentation of meetings with the patient to assess the home health services and supportive services provided to the patient;

13. 15. The disposition of the patient upon discharge;

14. 16. The discharge plan;

15. 17. Discharge instructions and discharge summary, if applicable;

16. 18. If applicable:

a. Laboratory reports,

b. Radiologic reports,

c. Diagnostic reports, and

d. Consultation reports;

17. 19. 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;

18. 20. Documentation of tasks assigned to a home health aide or other personnel member;

19. 21. Documentation of coordination of patient care;

20. 22. Copies of patient summary reports sent to the patient's physician, registered nurse practitioner, or podiatrist, as applicable; and

21. 23. Documentation of contacts with the patient's physician, registered nurse practitioner, or podiatrist, as applicable, by a personnel member or the patient.

Notes

Ariz. Admin. Code § R9-10-1209

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.