Section R9-10-1607. Medical Records

A.      A provider shall ensure that:

1.        A medical record is established and maintained for each recipient according to A.R.S. Title 12, Chapter 13, Article 7.1;

2.        An entry in a recipient’s medical record is:

a.         Only recorded by the provider or an individual des- ignated by the provider to record an entry;

b.        Dated, legible, and authenticated; and

c.         Not changed to make the initial entry illegible;

3.        A recipient’s medical record is available to an individual:

a.         Authorized by policies and procedures to access the recipient’s medical record;

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

c.         As permitted by law; and

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

B.       If a provider maintains recipients’ medical records electroni- cally, the provider shall ensure that safeguards exist to pre- vent unauthorized access.

C.      A provider shall ensure that a recipient’s medical record con- tains:

1.        Recipient information that includes:

a.         The recipient’s name,

b.        The recipient’s date of birth,

c.         Any known allergies, and

d.        Medication information for the recipient;

2.        The names, addresses, and telephone numbers of:

a.         The recipient’s medical practitioner;

b.        The recipient’s case manager, if applicable;

c.         The behavioral health professional assigned to the recipient by the behavioral health respite home’s collaborating health care institution; and

d.        An individual to be contacted in the event of an emergency;

3.        The date and time of the recipient’s acceptance by the behavioral health respite home and, if applicable, the date and time of the recipient’s release from the behavioral health respite home;

4.        If applicable, the name and contact information of the recipient’s representative and:

a.         If the recipient is 18 years of age or older or an emancipated minor, the document signed by the recipient consenting for the recipient’s representa- tive to act on the recipient’s behalf; or

b.        If the recipient’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.        A copy of the recipient’s treatment plan and any updates to the recipient’s treatment plan obtained from the behav- ioral health respite home’s collaborating health care insti- tution;

6.        For a recipient receiving assistance in the self-administra- tion of medication, documentation that includes for each medication:

a.         The date and time of assistance;

b.        The name, strength, dosage, and route of administra- tion;

c.         The provider’s signature or first and last initials; and

d.        Any adverse reaction the recipient has to the medi- cation;

7.        Documentation of the recipient’s refusal of a medication, if applicable;

8.        Documentation of any significant change in the recipi- ent’s behavior or physical, cognitive, or functional condi- tion and the action taken by a provider to address the recipient’s changing needs;

9.        If applicable, documentation of any actions taken to con- trol the recipient’s sudden, intense, or out-of-control behavior to prevent harm to the recipient or another indi- vidual;

10.     If applicable, documentation of a notification to the behavioral health respite home’s collaborating health care institution of an unexpected self-release of the recipient; and

11.     A written notice of release from the behavioral health respite home, if applicable.

Historical Note

Section made by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Section R9-10- 1607 renumbered to R9-10-1608; new Section R9-10- 1607 renumbered from R9-10-1606 and amended by exempt rulemaking at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2).