Ariz. Admin. Code § R9-10-312 - 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;

6. 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

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

B. If a behavioral health inpatient 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;

b. The patient's address;

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 allergy, including medication allergies;

2. Medication information that includes:

a. Documentation of medication ordered for the patient; and

b. Documentation of medication administered to the patient that includes:

i. The date and time of administration;

ii. The name, strength, dosage, amount, and route of administration;

iii. For a medication administered for pain on a PRN basis:

(1) An assessment of the patient's pain before administering the medication, and

(2) The effect of the medication administered;

iv. For a psychotropic medication administered on a PRN basis:

(1) An assessment of the patient's behavior before administering the psychotropic medication, and

(2) The effect of the psychotropic medication administered;

iii. v. The identification and authentication of the individual administering the medication or providing assistance in the self-administration of the medication; and

iv. vi. Any adverse reaction the patient has to the medication;

3. If applicable, documented general consent and informed consent 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;

4. 5. The patient's medical history and results of a physical examination or an interval note;

5. 6. If the patient provides a health care directive, the health care directive signed by the patient or the patient's representative;

6. 7. An admitting diagnosis or presenting symptoms;

8. The date of admission and, if applicable, the date of discharge;

7. 9. The name of the admitting medical practitioner or behavioral health professional;

8. 10. Orders;

9. 11. The patient's nursing assessment and behavioral health assessment and any interval notes;

10. 12. Treatment plans;

11. 13. Documentation of behavioral health services and physical health services provided to the patient;

12. 14. Progress notes;

15. If applicable, documentation of restraint or seclusion;

16. If applicable, documentation that evacuation from the behavioral health inpatient facility would cause harm to the patient;

13. 17. The disposition of the patient after discharge;

14. 18. The discharge plan;

15. 19. The discharge summary; and

16. 20. If applicable:

a. A laboratory report,

b. A radiologic report,

c. A diagnostic report, and

d. Documentation of restraint or seclusion, and

e. d. A consultation report.

Notes

Ariz. Admin. Code § R9-10-312

Section R9-10-312, formerly numbered as R9-10-212, renumbered as an emergency effective February 22, 1979, pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 79-1). Adopted effective June 14, 1979 (Supp. 79-3). Former Section R9-10-312 repealed, new Section R9-10-312 adopted effective February 4, 1981 (Supp. 81-1). Section repealed by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). New Section R9-10-312 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.