Ariz. Admin. Code § R9-10-1807 - Medical Records

A. A provider 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. Only recorded by the provider or individual designated by the provider to record an entry;

b. Dated, legible, and authenticated; and

c. Not changed to make the initial entry illegible;

3. A resident's medical record is available to an individual:

a. Authorized by 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; and

4. A resident's medical record is protected from loss, damage, or unauthorized use.

B. If a provider maintains residents' medical records electronically, the provider shall ensure that safeguards exist to prevent unauthorized access.

C. A provider 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,

c. Any known allergies, and

d. Medication information for the resident;

2. The names, addresses, and telephone numbers of:

a. The resident's medical practitioner;

b. The resident's case manager, if applicable;

c. The behavioral health professional assigned to the resident by the adult behavioral health therapeutic home's collaborating health care institution; and

d. An individual to be contacted in the event of an emergency;

3. The date of the resident's acceptance by the adult behavioral health therapeutic home and, if applicable, the date of the resident's release from the adult behavioral health therapeutic home;

4. 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;

5. A copy of the resident's treatment plan and any updates to the resident's treatment plan, obtained from the adult behavioral health therapeutic home's collaborating health care institution;

6. For a resident receiving assistance in the self-administration of medication, documentation that includes for each medication:

a. The date and time of assistance;

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

c. The provider's signature or first and last initials; and

d. Any adverse reaction the resident has to the medication;

7. Documentation of the resident's refusal of a medication, if applicable;

8. Documentation of any significant change in a resident's behavior or physical, cognitive, or functional condition and the action taken by a provider to address the resident's changing needs;

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

10. If applicable, a written notice of termination of residency.

Notes

Ariz. Admin. Code § R9-10-1807

New Section made by exempt rulemaking at 20 A.A.R. 1409, effective 7/1/2014.