Ariz. Admin. Code § R9-10-512 - Medical Records
A. An
administrator shall ensure that:
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. A
resident's medical record is protected from loss, damage, or unauthorized
use.
B. If an ICF/IID
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:
1.
Resident information that includes:
a. The
resident's name;
b. The resident's
date of birth; and
c. Any known
allergies, including medication allergies;
2. The admission date and, if applicable, the
date of discharge;
3. The admitting
diagnosis or presenting symptoms;
4. Documentation of the resident's placement
evaluation;
5. Documentation of
general consent and, if applicable, informed consent;
6. 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;
7. The name and contact information of an
individual to be contacted under
R9-10-503(I);
8. Documentation of the initial assessment
required in
R9-10-507(3)
to determine acuity;
9. The medical
history and physical examination required in
R9-10-516(A)(4);
10. A copy of the resident's living will or
other health care directive, if applicable;
11. The name and telephone number of the
resident's attending physician;
12.
Orders;
13. Documentation of the
resident's comprehensive assessment;
14. Individual program plans, including
nursing care plans or medical care plans, if applicable;
15. Documentation of active treatment and
other physical health services or behavioral care provided to the
resident;
16. Progress notes,
including data needed to evaluate the effectiveness of the methods, schedule,
and strategies being used to accomplish the goals in the resident's individual
program plan;
17. If applicable,
documentation of restraint or seclusion;
18. If applicable, documentation of any
actions other than restraint or seclusion taken to control or address the
resident's behavior to prevent harm to the resident or another individual or to
improve the resident's social interactions;
19. If applicable, documentation that
evacuation from the ICF/IID would cause harm to the resident;
20. The disposition of the resident after
discharge;
21. The discharge
plan;
22. The discharge
summary;
23. Transfer
documentation;
24. If applicable:
a. A laboratory report,
b. A radiologic report,
c. A diagnostic report, and
d. A consultation report;
25. Documentation of freedom from
infectious tuberculosis required in
R9-10-507(10);
26. Documentation of a medication
administered to the resident that includes:
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; and
27. If
applicable, a copy of written notices, including follow-up instructions,
provided to the resident or the resident's representative.
Notes
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No prior version found.