Ariz. Admin. Code § R9-10-1908 - 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 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 patient'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 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 a counseling facility 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 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 and address, and

b. The patient's date of birth;

2. A diagnosis or reason for counseling;

3. Documentation of general consent and, if applicable, informed consent for counseling by the patient or the patient's representative;

4. 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;

5. Documentation of medical history;

6. Orders;

7. Assessment;

8. Interval notes;

9. Progress notes;

10. Documentation of counseling provided to the patient;

11. The name of each individual providing counseling;

12. Disposition of the patient upon discharge;

13. Documentation of the patient's follow-up instructions provided to the patient;

14. A discharge summary; and

15. 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.

Notes

Ariz. Admin. Code § R9-10-1908

Adopted by exempt rulemaking at 20 A.A.R. 3535, effective 1/1/2015.