Ariz. Admin. Code § R9-10-611 - Medical Records

A. An administrator shall ensure that:

1. A patient's 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 according to policies and procedures; and

c. If the order is a verbal order, authenticated by the medical practitioner 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 e signature represents is accountable for the use of the rubber-stamp signature or electronic e 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 a patient or the patient's representative; or

c. As permitted by law; and

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

B. If a hospice 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 patient's 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. The patient's name,

b. The patient's address,

c. The patient's telephone number,

d. The patient's date of birth, and

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

f. e. Any known allergy;

2. The admission date and, if applicable, the date that the patient stopped receiving services from the hospice;

3. The name and telephone number of the patient's physician;

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. Is a legal guardian, a copy of the court order establishing guardianship; or

ii. 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;

4. 5. The admitting diagnosis;

5. 6. If applicable, documented general consent and informed consent, by the patient or the patient's representative ;

6. 7. Documentation of medical history;

7. 8. A copy of the patient's living will, health care power of attorney, or other health care directive, if applicable;

8. 9. Orders;

9. 10. The assessment required in R9-10-607(B)(1) ;

10. 11. Care plans;

11. 12. Progress notes for each patient contact, including:

a. The date of the patient contact,

b. The services provided,

c. A description of the patient's condition, and

d. Instructions given to the patient or patient's representative;

12. 13. Documentation of hospice services provided to the patient;

13. 14. 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;

14. 15. Documentation of coordination of patient care;

15. 16. Documentation of contacts with the patient's physician by a personnel member;

16. 17. The discharge summary, if applicable;

17. 18. If applicable, transfer documentation from a sending health care institution; and

18. 19. 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, when initially administered or when administered on a PRN basis:

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, when initially administered or when administered on a PRN basis:

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 the medication; and

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

Notes

Ariz. Admin. Code § R9-10-611

Adopted effective November 6, 1978 (Supp. 78-6). Section R9-10-611 repealed effective November 1, 1998, under an exemption from the provisions of the Administrative Procedure Act pursuant to Laws 1998, Ch. 178, § 17; filed with the Office of the Secretary of State October 2, 1998 (Supp. 98-4). 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.

The following Section was repealed under an exemption from the provisions of the Administrative Procedure Act which means these rules were not reviewed by the Governor's Regulatory Review Council; the Department did not submit notice of proposed rulemaking to the Secretary of State for publication in the Arizona Administrative Register; and the Department was not required to hold public hearings on the repealing of these rules.