Ariz. Admin. Code § R9-10-811 - Medical Records
A. A manager
shall ensure that:6.
5. A resident's medical
record is protected from loss, damage, or unauthorized use.
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 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. 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;
4. A resident's medical
record is available to an individual: 5.
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
a.
Authorized according to policies and procedures to access the resident's
medical record;
c. As
permitted by law; and
B. If an assisted living facility
maintains residents' medical records electronically, a manager shall ensure
that:
1. Safeguards exist to prevent
unauthorized access, and
2. The
date and time of an entry in a resident's medical record is recorded by the
computer's internal clock.
C. A manager shall ensure that a resident's
medical record contains: 3.
4. The
date of acceptance and, if applicable, date of termination of
residency;
5.
6. Documentation of general consent and informed
consent, if applicable;
6.
7. Except as allowed in
R9-10-808(B)(2),
documentation of freedom from infectious tuberculosis as required in
R9-10-807(A)
;
7.
8. A copy of resident's health care directive, if
applicable;
8.
9. The resident's signed residency agreement and any
amendments;
9.
10. Resident's service plan and updates;
10.
11.
Documentation of assisted living services provided to the resident;
11.
12. A
medication order from a medical practitioner for each medication that is
administered to the resident or for which the resident receives assistance in
the self-administration of the medication;
12.
13. Documentation of
medication administered to the resident or for which the resident received
assistance in the self-administration of medication that includes:
13.
14. Documentation of
the resident's refusal of a medication, if applicable;
14.
17. Documentation of notification of the resident of
the availability of vaccination for influenza and pneumonia, according to
A.R.S. §
36-406(1)(d);
15.
18.
Documentation of the resident's orientation to exits from the assisted living
facility required in
R9-10-818(B)
;
16.
19. If a resident is receiving behavioral health
services other than behavioral care, documentation of the determination in
R9-10-813(3)
;
17.
20. If a resident is receiving behavioral care,
documentation of the determination in
R9-10-812(3) ;
19.
21. If applicable, for
a resident who is unable to direct self-care, the information required in
R9-10-815(F)
;
20.
22. Documentation of any significant change in a
resident's behavior, physical, cognitive, or functional condition and the
action taken by a manager or caregiver to address the resident's changing
needs;
21.
23. Documentation of the notification required in
R9-10-803(G) if
the resident is incapable of handling financial affairs; and
22.
24.
If the resident no longer resides and receives assisted living services from
the assisted living facility:
1. Resident
information that includes:
a. The resident's
name, and
b. The resident's date of
birth;
c. The name and contact
information of the resident's representative, if applicable;
2. The names,
addresses, and telephone numbers of:
a. The
resident's primary care provider;
b. Other persons, such as a home health
agency or hospice service agency, involved in the care of the resident;
and
c. An individual to be
contacted in the event of emergency, significant change in the resident's
condition, or termination of residency;
3. 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;
a. The date and time of administration or
assistance;
b. The name, strength,
dosage, and route of administration;
c. The name and signature of the individual
administering or providing assistance in the self-administration of medication;
and
d. An unexpected reaction the
resident has to the medication;
15. 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;
16. If applicable, documentation of a
determination by a medical practitioner that evacuation from the assisted
living facility during an evacuation drill would cause harm to the
resident;
18. If applicable, documentation
that evacuation from the assisted living facility during a drill may cause
physical harm to the resident;
a. A written
notice of termination of residency; or
b. If the resident terminated residency, the
date the resident terminated residency.
Notes
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