Section R9-10-411. Medical Records

A.      An administrator shall ensure that:

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

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

a.         Recorded only by an individual authorized by poli- cies 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 resident’s medical 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 resident’s medical record is available to an individual:

a.         Authorized to access the resident's medial record according to policies and procedures;

b.        If the individual is not authorized to access the resi- dent's medical record according to policies and pro- cedures, with the written consent of the resident or the resident's representative; or

c.         As permitted by law; and

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

B.       If  a  nursing  care  institution  maintains   residents’  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 resident’s medical record is recorded by the computer's internal clock.

C.      An administrator shall ensure that a resident’s medical record contains:

1.        Resident information that includes:

a.         The resident's name;

b.        The resident's date of birth; and

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

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

3.        The admitting diagnosis or presenting symptoms;

4.        Documentation  of  general  consent  and,  if   applicable, informed consent;

5.        If applicable, the name and contact information of the resident’s representative and:

a.         The document signed by the resident consenting for the resident’s representative to act on the resident’s behalf; or

b.        If the resident’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;

6.        The medical history and physical examination required in R9-10-407(6);

7.        A copy of the resident's living will or other health care directive, if applicable;

8.        The name and telephone number of the resident's attend- ing physician;

9.        Orders;

10.     Care plans;

11.     Behavioral care plans, if the resident is receiving behav- ioral care;

12.     Documentation of nursing care institution services pro- vided to the resident;

13.     Progress notes;

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

15.     If applicable, documentation that evacuation from the nursing care institution would cause harm to the resident;

16.     The disposition of the resident after discharge;

17.     The discharge plan;

18.     The discharge summary;

19.     Transfer documentation;

20.     If applicable:

a.         A laboratory report,

b.        A radiologic report,

c.         A diagnostic report, and

d.        A consultation report;

21.     Documentation of freedom from infectious tuberculosis required in R9-10-407(7);

22.     Documentation of a medication administered to the resi- dent that includes:

a.         The date and time of administration;

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

c.         The type of vaccine, if applicable;

d.        For a medication administered for pain on a PRN basis:

i.         An evaluation of the resident’s pain before administering the medication, and

ii.        The effect of the medication administered;

e.         For a psychotropic medication administered on a PRN basis:

i.         An evaluation of the resident’s symptoms before administering the psychotropic medica- tion, and

ii.        The effect of the psychotropic medication administered;

f.         The identification, signature, and professional desig- nation of the individual administering the medica- tion; and

g.        Any adverse reaction a resident has to the medica- tion;

23.     If the resident has been assessed for receiving nutrition and feeding assistance from a nutrition and feeding assis- tant, documentation of the assessment and the determina- tion of eligibility; and

24.     If applicable, a copy of written notices, including follow- up instructions, provided to the resident or the resident’s representative.

Historical Note

Adopted effective January 28, 1980 (Supp. 80-1). Section repealed by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). New Section R9-10-411 made by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt

rulemaking at 19 A.A.R. 3334, effective October 1, 2013 (Supp. 13-4). Amended by exempt rulemaking at 20

A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effec- tive July 1, 2014 (Supp. 14-2).