Ariz. Admin. Code § R9-10-1111 - Medical Records

A. An administrator shall ensure that:

1. A medical record is established and maintained for a participant according to A.R.S. Title 12, Chapter 13, Article 7.1;

2. An entry in a participant'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 participant'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. 3. 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 e signature represents is accountable for the use of the rubber-stamp signature or electronic e signature;

5. 4. A participant's medical record is available to an individual:

a. Authorized according to policies and procedures to access the participant's medical record;

6. b. If the individual is not authorized according to policies and procedures, with the written consent of the participant or the participant's representative; or

c. As permitted by law; and

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

B. If an adult day health care facility maintains participant's 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 participant's medical record is recorded by the computer's internal clock.

C. An administrator shall ensure that a participant's medical record contains:

1. Participant information that includes:

a. The participant's name;

b. The participant's address;

c. The participant's date of birth; and

d. The name and contact information of the participant's representative, if applicable; and

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

2. The name of the participant's medical practitioner or other individuals involved in the care of the participant;

3. An enrollment agreement and date of the participant's first visit;

4. If applicable, documented general consent and informed consent by the participant or the participant's representative;

5. If applicable, the name and contact information of the participant's representative and:

a. The document signed by the participant consenting for the participant's representative to act on the participant's behalf; or

b. If the participant'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;

5. 6. Documentation of medical history;

6. 7. A copy of the participant's health care directive, if applicable;

7. 8. Orders;

8. 9. The medical assessment required in R9-10-1107(D) ;

9. 10. A care plan;

10. 11. The comprehensive assessment required in R9-10-1107(F) ;

11. 12. Progress notes;

13. If applicable, documentation of any actions taken to control the participant's sudden, intense, or out-of-control behavior to prevent harm to the participant or another individual;

12. 14. Documentation of adult day health services provided to the participant;

13. 15. The disposition of the participant upon discharge;

14. 16. The discharge date, if applicable;

15. 17. Documentation of a medication administered to the participant that includes:

a. The date and time of administration;

b. The name, strength, dosage, and route of administration;

c. The identification and signature of the individual administering, providing assistance in the self-administration of medication, or observing the participant's self-administration of the medication;

d. If medication for pain is administered on a PRN basis to a participant:

i. An identification of the participant's pain before administering the medication, and

ii. The effect of the medication administered; and

e. Any adverse reaction a participant has to the medication;

17. 18. If applicable, documentation of:

a. A significant change in the participant's condition,

b. An injury or accident that occurred at the adult day health care facility and required medical services, and

c. Notification provided to the participant's medical practitioner or the participant's representative of the significant change in subsection (C)(18)(a) or the injury or accident in subsection (C)(18)(b);

18. 19. Documentation of whether the participant may sign in or out of the adult day health care facility;

19. 20. Documentation of freedom from infectious tuberculosis required in R9-10-1107(A) ; and

20. 21. Names and telephone numbers of individuals to be notified in the event of an emergency.

Notes

Ariz. Admin. Code § R9-10-1111

Amended effective September 2, 1977 (Supp. 77-5). Repealed effective July 22, 1994 (Supp. 94-3). New Section 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.