Ariz. Admin. Code § R9-10-1410 - Medical Records

A. An administrator shall ensure that:

1. A medical record is established and maintained for each 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 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 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. 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 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. 6. A participant's medical record is protected from loss, damage, or unauthorized use.

B. If a substance abuse transitional agency maintains participants' 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 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. A participant's presenting behavioral health issue;

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

4. 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;

4. 5. Documentation of medical history and results of a physical examination;

6. The date of admission and, if applicable, date of discharge;

5. 7. Orders;

6. 8. Assessment;

7. 9. Progress notes;

8. 10. Documentation of substance abuse transitional agency services provided to the participant;

11. 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;

9. 12. The disposition of the participant upon discharge;

10. 13 The discharge plan;

11.14A discharge summary, if applicable; and

12.15.Documentation of a medication administered to a participant 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 evaluation of the participant's pain before administering the medication, and

ii. The effect of the medication administered;

d. For a psychotropic medication:

i. An evaluation of the participant's behavior before administering the psychotropic medication, and

ii. The effect of the psychotropic medication administered;

e. The signature of the individual administering the medication; and

f. Any adverse reaction a participant has to the medication.

Notes

Ariz. Admin. Code § R9-10-1410

Adopted effective February 1, 1994 (Supp. 94-1). Section repealed; 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.