Section R9-10-1708. 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 a personnel member authorized by policies and procedures to make the entry;

b.        Dated, legible, and authenticated; and

c.         Not changed to make the 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  a  health  care  institution   maintains  a  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.        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;

2.        The name of the admitting medical practitioner or behav- ioral health professional;

3.        The date of admission and, if applicable, the date of dis- charge;

4.        An admitting diagnosis;

5.        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.         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;

6.        If applicable, documented general consent and informed consent by the patient or the patient’s representative;

7.        Documentation of medical history and results of a physi- cal examination;

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

9.        Orders;

10.     Assessment;

11.     Treatment plans;

12.     Interval note;

13.     Progress notes;

14.     Documentation of health care institution services pro- vided to the patient;

15.     Disposition of the patient after discharge;

16.     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;

17.     Discharge plan;

18.     A discharge summary, if applicable;

19.     If applicable:

a.         Laboratory reports,

b.        Radiologic reports,

c.         Diagnostic reports, and

d.        Consultation reports; and

20.     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, when ini- tially administered or PRN:

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,   when    initially administered or PRN:

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; and

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

Historical Note

Adopted effective July 6, 1994 (Supp. 94-3). Section repealed; 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, pur- suant to Laws 2013, Ch. 10, § 13; effective July 1, 2014

(Supp. 14-2).