Ariz. Admin. Code § R9-10-411 - Medical Records
A. An
administrator shall ensure that:
7.
6. A resident's medical
record is protected from loss, damage, or unauthorized use.
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 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
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 to access the resident's medial record according to policies and
procedures;
b. If the individual is
not authorized to access the resident's medical record according to policies
and procedures, with the written consent of the resident or the resident's
representative; or
c. As permitted
by law; and
6.
Information in a resident's medical record is
disclosed to an individual not authorized under subsection (A)(5) only with the
written consent of the resident or the resident's representative or as
permitted by law; and
B. If a nursing care institution
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:
5.
6. The medical history and physical examination
required in R9-10-407(6);
6.
7. A copy of the
resident's living will or other health care directive, if applicable;
7.
8. The
name and telephone number of the resident's attending physician;
8.
9.
Orders;
9.
10. Care plans;
10.
11. Behavioral care plans, if the resident is
receiving behavioral care;
11.
12. Documentation of
nursing care institution services provided to the resident;
12.
13.
Progress notes;
13.
16. The disposition of
the resident after discharge;
14.
17. The discharge
plan;
15.
18. The discharge summary;
16.
19. Transfer
documentation;
17.
20. If applicable:
e.
d. A consultation report;
18.
21.
Documentation of freedom from infectious tuberculosis required in
R9-10-407(7);
19.
22. Documentation of a medication administered to the
resident that includes:
20.
23. If the resident
has been assessed for receiving nutrition and feeding assistance from a
nutrition and feeding assistant, documentation of the assessment and the
determination of eligibility; and
21.
24. If applicable, a
copy of written notices, including follow-up instructions, provided to the
resident or the resident's representative.
1.
Resident information that includes:
d.
c. Any known allergies,
including medication allergies;
a. The
resident's name;
b. The resident's
date of birth; and
c.
The name and contact information of the resident's
representative, if applicable; and
2. The admission date and, if applicable, the
date of discharge;
3. The admitting
diagnosis or presenting symptoms;
4. Documentation of general consent and, if
applicable, informed consent;
5. If
applicable, the name and contact information of the resident's representative
and:
a. 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;
14. If applicable,
documentation of any actions taken to control the resident's sudden, intense,
or out-of-control behavior to prevent harm to the resident or another
individual;
15. If applicable,
documentation that evacuation from the nursing care institution would cause
harm to the resident;
a. A laboratory report,
b. A radiologic report,
c. A diagnostic report, and
d.
Documentation of restraint or seclusion,
and
a. The date and time
of administration;
b. The name,
strength, dosage, and route of administration;
c. The type of vaccine, if
applicable;
d. For a medication
administered for pain on a PRN basis:
i. An
evaluation of the resident's pain before administering the medication,
and
ii. The effect of the
medication administered;
e. For a psychotropic medication administered
on a PRN basis:
i. An evaluation of the
resident's symptoms before administering the psychotropic medication,
and
ii. The effect of the
psychotropic medication administered;
f. The identification, signature, and
professional designation of the individual administering the medication;
and
g. Any adverse reaction a
resident has to the medication;
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.