Section R9-10-213. 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 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 staff member according to policies and procedures; and

c.         If the order is a verbal order, authenticated by a med- ical staff member or medical practitioner;

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 personnel mem- bers and medical staff members authorized by policies and procedures to access the medical record;

6.        Policies and procedures include the maximum time-frame to retrieve an onsite or off-site patient’s medical record at the request of a medical staff member or authorized per- sonnel member; and

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

B.       If a hospital 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 patient’s medical record is recorded by the computer's internal clock.

C.      An administrator shall ensure that a medical record for an inpatient 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 allergy, including medication allergies or sensitivities;

2.        Medication information that includes:

a.         A medication ordered for the patient; and

b.        A medication administered to the patient including:

i.         The date and time of administration;

ii.        The name, strength, dosage, amount, and route of administration;

iii.      The   identification  and  authentication  of  the individual administering the medication; and

iv.       Any   adverse  reaction  the   patient  has  to   the medication;

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.        A medical history and results of a physical examination or an interval note;

5.        If the patient provides a health care directive, the health care directive signed by the patient;

6.        An admitting diagnosis;

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

8.        Names of the admitting medical staff member and medi- cal practitioners coordinating the patient’s care;

9.        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;

f.         Documentation of restraint or seclusion, and

g.        A consultation report.

E.       In addition to the requirements in subsection (D), an adminis- trator shall ensure that the hospital’s record of emergency ser- vices provided to a patient contains:

1.        Documentation of treatment the patient received before arrival at the hospital, if available;

2.        The patient’s medical history;

3.        An assessment, including the name of the individual per- forming the assessment;

4.        The patient’s chief complaint;

5.        The name of the individual who treated the patient in the emergency room, if applicable; and

6.        The disposition of the patient after discharge.

10.     Orders;

11.     Care plans;

12.     Documentation  of  hospital  services  provided  to  the patient;

13.     Progress notes;

14.     The disposition of the patient after discharge;

15.     Discharge  planning,  including  discharge  instructions required in R9-10-209(B)(3);

16.     A discharge summary; and

17.     If applicable:

a.         A laboratory report,

b.        A pathology report,

c.         An autopsy report,

d.        A radiologic report,

e.         A diagnostic imaging report,

f.         Documentation of restraint or seclusion, and

g.        A consultation report.

D.      An administrator shall ensure that a hospital's medical record for an outpatient contains:

1.        Patient information that includes:

a.         The patient’s name;

b.        The patient’s address;

c.         The patient’s date of birth;

d.        The name and contact information of the patient’s representative, if applicable; and

e.         Any known allergy including medication allergies or sensitivities;

2.        If necessary for treatment, medication information that includes:

a.         A medication ordered for the patient; and

b.        A medication administered to the patient including:

i.         The date and time of administration;

ii.        The name, strength, dosage, amount, and route of administration;

iii.      The  identification  and  authentication  of   the individual administering the medication; and

iv.       Any   adverse  reaction  the  patient  has  to  the medication;

3.        Documentation of general and, if applicable, informed consent for treatment by the patient or the patient's repre- sentative, except in an emergency;

4.        An admitting diagnosis or reason for outpatient medical services;

5.        Orders;

6.        Documentation  of  hospital  services  provided  to  the patient; and

7.        If applicable:

a.         A laboratory report,

b.        A pathology report,

c.         An autopsy report,

d.        A radiologic report,

e.         A diagnostic imaging report,

Historical Note

Former Section R9-10-213 renumbered as R9-10-313 as an emergency effective February 23, 1979, new Section R9-10-213 adopted effective February 23, 1979 (Supp. 79-1). Section repealed; new Section made by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). Amended by final rulemaking at 11 A.A.R.

536, effective March 5, 2005 (Supp. 05-1). Section R9- 10-213 renumbered to R9-10-211; new Section R9-10- 213 renumbered from R9-10-228 and amended 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).