Ariz. Admin. Code § R9-10-1009 - 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;

7. 6. Policies and procedures include the maximum time-frame to retrieve a patient's medical record at the request of a medical practitioner, behavioral health professional, or authorized personnel member; and

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

B. If an outpatient treatment center 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. Except as specified in A.A.C. R9-6-1005, the patient's name and address;

b. The patient's date of birth; and

c. The name and contact information of the patient's representative, if applicable; and

d. c. Any known allergies, including medication allergies;

2. A diagnosis or reason for outpatient treatment center services;

3. Documentation of general consent and, if applicable, informed consent for treatment by the patient or the patient's representative, except in an emergency;

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. Documentation of medical history and, if applicable, results of a physical examination;

5. 6. Orders;

6. 7. Assessment;

7. 8. Treatment plans;

8. 9. Interval notes;

9. 10. Progress notes;

10. 11. Documentation of outpatient treatment center services provided to the patient;

11. 12. The name of each individual providing treatment or a diagnostic procedure;

12. 13. Disposition of the patient upon discharge;

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

14. 15. A discharge summary;

15. 16. If applicable:

a. Laboratory reports,

b. Radiologic reports,

c. Sleep disorder reports,

d. Diagnostic reports, and

e. Documentation of restraint or seclusion, and

f. e. Consultation reports;

17. 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, other than actions taken while providing behavioral health observation/stabilization services; and

16. 18. Documentation of a medication administered to the patient 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:

i. An assessment of the patient's pain before administering the medication, and

ii. The effect of the medication administered;

d. For a psychotropic medication:

i. An assessment of the patient'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 observing the self-administration of the medication;

f. Any adverse reaction a patient has to the medication; and

g. For prepacked or sample medication provided to the patient for self-administration, the name, strength, dosage, amount, route of administration, and expiration date.

Notes

Ariz. Admin. Code § R9-10-1009

New Section made by final rulemaking at 14 A.A.R. 294, effective March 8, 2008 (Supp. 08-1). Section amended 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.