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 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
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 according to policies and procedures to access the resident's
medical record;
b. If the
individual is not authorized according to policies and procedures, with the
written consent of the resident or the resident's representative; or
c. As permitted by law;
6. Policies and procedures include the
maximum time-frame to retrieve a resident's medical record at the request of a
medical practitioner, behavioral health professional, or authorized personnel
member; and
7. A resident's medical
record is protected from loss, damage, or unauthorized use.
B. If a behavioral health
residential facility 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 address;
c. The resident's date of birth;
and
d. Any known allergies,
including medication allergies;
2. The name of the admitting medical
practitioner or behavioral health professional;
3. An admitting diagnosis or presenting
behavioral health issues;
4. The
date of admission and, if applicable, date of discharge;
5. If applicable, the name and contact
information of the resident's representative and:
a. If the resident is 18 years of age or
older or an emancipated minor, 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;
6. If applicable, documented general consent
and informed consent for treatment by the resident or the resident's
representative;
7. Documentation of
medical history and results of a physical examination;
8. A copy of resident's health care
directive, if applicable;
9.
Orders;
10. If applicable,
documentation that evaluation or treatment was ordered by a court according to
A.R.S. Title 36, Chapter 5 or A.R.S. §
8-341.01;
10.11.
Assessment;
11.12. Treatment
plans;
12.13. Interval
notes;
13.14. Progress
notes;
14.15. Documentation of
behavioral health services and physical health services provided to the
resident;
15.16. If applicable,
documentation of the use of an emergency safety response;
16.17. If
applicable, documentation of time-out required in
R9-10-714(6);
17.18.
Except as allowed in
R9-10-707(E)(1)(d),
documentation of freedom from infectious tuberculosis required in
R9-10-707(A)(13);
18.19.
The disposition of the resident after discharge;
19.20. The discharge plan;
20.21. The discharge
summary, if applicable;
21.22. If applicable:
a. Laboratory reports,
b. Radiologic reports,
c. Diagnostic reports, and
d. Consultation reports;
and
22.
23. Documentation of medication administered to the
resident 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,
when administered initially or on a PRN basis:
i. An assessment of the resident's pain
before administering the medication, and
ii. The effect of the medication
administered;
d. For a
psychotropic medication, when administered initially or on a PRN basis:
i. An assessment of the resident'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 providing assistance in the self-administration of the
medication; and
f. Any adverse
reaction a resident has to the medication.