Arizona Administrative Code (Last Updated: November 17, 2016) |
Title 9. HEALTH SERVICES |
Chapter 10. DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING |
Article 10. OUTPATIENT TREATMENT CENTERS |
Section R9-10-1009. Medical Records
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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).