Section R9-10-1009. Medical Records  


Latest version.

All data is extracted from pdf, click here to view the pdf.

  • A.      An administrator shall ensure that:

    1.        A 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 med- ical record and includes the time of the order;

    b.        Authenticated by a medical practitioner or behav- ioral health professional according to policies and procedures; and

    c.         If the order is a verbal order, authenticated by the medical practitioner or behavioral health profes- sional issuing the order;

    4.        If a rubber-stamp signature or an electronic signature is used to authenticate an order, the individual whose signa- ture the rubber-stamp signature or electronic signature represents is accountable for the use of the rubber-stamp signature or electronic 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;

    b.        If the individual is not authorized according to poli- cies and procedures, with the written consent of the patient or the patient’s representative; or

    c.         As permitted by law;

    6.        Policies and procedures include the maximum time-frame to retrieve a patient’s medical record at the request of a medical practitioner, behavioral health professional, or authorized personnel member; and

    7.        A patient’s medical record is protected from loss, dam- age, or unauthorized use.

    B.       If an outpatient treatment center 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 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.         Except as specified in A.A.C. R9-6-1005, the patient’s name and address;

    b.        The patient’s date of birth; and

    c.         Any known allergies, including medication aller- gies;

    2.        A diagnosis or reason for outpatient treatment center ser- vices;

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

    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 eman- cipated 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.         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 attor- ney or mental health care power of attorney; or

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

    5.        Documentation  of  medical  history  and,  if  applicable, results of a physical examination;

    6.        Orders;

    7.        Assessment;

    8.        Treatment plans;

    9.        Interval notes;

    10.     Progress notes;

    11.     Documentation of outpatient treatment center services provided to the patient;

    12.     The name of each individual providing treatment or a diagnostic procedure;

    13.     Disposition of the patient upon discharge;

    14.     Documentation  of  the  patient’s  follow-up   instructions provided to the patient;

    15.     A discharge summary;

    16.     If applicable:

    a.         Laboratory reports,

    b.        Radiologic reports,

    c.         Sleep disorder reports,

    d.        Diagnostic reports, and

    e.         Consultation reports;

    17.     If applicable, documentation of any actions taken to con- trol the patient’s sudden, intense, or out-of-control behav- ior to prevent harm to the patient or another individual, other than actions taken while providing behavioral health observation/stabilization services; and

    18.     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 administra- tion;

    c.         For a medication administered for pain:

    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:

    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 desig- nation of the individual administering or observing the self-administration of the medication;

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

    g.        For prepacked or sample medication provided to the patient for self-administration, the name, strength, dosage, amount, route of administration, and expira- tion date.

Historical Note

New Section made by final rulemaking at 14 A.A.R. 294, effective March 8, 2008 (Supp. 08-1). Section amended by exempt rulemaking at 19 A.A.R. 2015, effective Octo- ber 1, 2013 (Supp. 13-2). Amended by exempt rulemak-

ing at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, §

13; effective July 1, 2014 (Supp. 14-2).