Section R9-10-1312. Medical Records

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 an individual authorized by facil- ity 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 facility poli- cies 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 the 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.        A patient’s medical record is available to the patient or patient’s representative upon request at a time agreed upon by the patient or patient’s representative and the administrator; and

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

B.       If a behavioral health specialized transitional facility maintains patient’s 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.        A copy of the court order requiring the patient to be detained at or committed to the behavioral health special- ized transitional facility;

2.        The date the patient was detained at or committed to the behavioral health specialized transitional facility;

3.        Patient information that includes:

a.         The patient’s name;

b.        The patient’s address;

c.         The patient’s date of birth; and

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

4.        Documentation of the patient’s freedom from infectious tuberculosis as required in R9-10-1306(C)(2);

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

6.        If applicable, the name and contact information of the patient’s representative and:

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

7.        Documentation of medical history and physical examina- tion of the patient;

8.        A copy of patient’s health care directives, if applicable;

9.        Orders;

10.     The patient’s assessment including updates;

11.     The patient’s treatment plan including updates;

12.     Progress notes;

13.     Documentation of transportation provided to the patient;

14.     Documentation of behavioral health services and physical health services provided to the patient;

15.     Documentation  of  patient’s  annual  examination  and report required by A.R.S. § 36-3708;

16.     Documentation of the annual written notice of the patient of the patient’s right to petition for:

a.         Conditional release to a less restrictive alternative as required by A.R.S. § 36-3709, or

b.        Discharged as required by A.R.S. § 36-3714;

17.     A copy of any petition for discharge or conditional release to a less restrictive alternative filed by the patient and provided to the behavioral health specialized transi- tional facility and the outcome of the petition;

18.     Documentation of the patient’s, if applicable;

a.         Conditional release to a less restrictive alternative; or

b.        Discharge, including the disposition of the patient upon discharge;

19.     If a patient has been discharged, a discharge summary that includes:

a.         A summary of the treatment provided to the patient;

b.        The patient’s progress in meeting treatment goals, including treatment goals that were and were not achieved;

c.         The name, dosage, and frequency of each medica- tion for the patient ordered at the time of the patient’s discharge from the behavioral health spe- cialized transitional facility;

d.        A description of the disposition of the patient’s pos- sessions, funds, or medications; and

e.         The date the patient was discharged from the behav- ioral health specialized transitional facility;

20.     If applicable:

a.         Laboratory reports,

b.        Radiologic reports,

c.         Diagnostic reports,

d.        Documentation of restraint,

e.         Patient follow-up instructions, and

f.         Consultation reports; and

21.     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.        If applicable, a patient’s refusal to take medication ordered for the patient.

Historical Note

Emergency rule adopted effective November 29, 1991, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 91-4). Emergency rule adopted again effective February 28, 1992, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 92-1). Emergency rule adopted again effective May 28, 1992, pursuant to A.R.S. § 41- 1026, valid for only 90 days (Supp. 92-2). Emergency rule adopted again effective August 27, 1992, pursuant to

A.R.S. § 41-1026, valid for only 90 days (Supp. 92-3). Adopted with changes effective November 25, 1992 (Supp. 92-4). Section R9-10-1312 repealed effective

November 1, 1998, under an exemption from the provi- sions 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, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2).