Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING
Article 11 - ADULT DAY HEALTH CARE FACILITIES
Section R9-10-1111 - Medical Records
Universal Citation: AZ Admin Code R 9-10-1111
Current through Register Vol. 30, No. 38, September 20, 2024
A. An administrator shall ensure that:
1. A medical
record is established and maintained for a participant according to A.R.S.
Title 12, Chapter 13, Article 7.1;
2. An entry in a participant's medical record
is:
a. Recorded only by an individual
authorized by policies and procedures to make the entry;
b. Dated, legible, and authenticated;
and
c. Not changed to make the
initial entry illegible;
he medical practitioner or ;
3. If
a rubber-stamp signature or an electronic signature is used to authenticate an
order, the individual whose signature the rubber-stamp signature or electronic
e signature represents is accountable for the use of the rubber-stamp signature
or electronic e signature;
4. A participant's
medical record is available to an individual:
a. Authorized according to policies and
procedures to access the participant's medical record;
b. If
the individual is not authorized according to policies and procedures, with the
written consent of the participant or the participant's representative;
or
c. As permitted by law;
and
5. A participant's medical record is protected from
loss, damage, or unauthorized use.
B. If an adult day health care facility maintains participant'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 participant's medical record is recorded by the
computer's internal clock.
C. An administrator shall ensure that a participant's medical record contains:
1.
Participant information that includes:
a. The
participant's name;
b. The
participant's address;
c. The
participant's date of birth; and
d. Any known allergies, including medication
allergies;
2. The name
of the participant's medical practitioner or other individuals involved in the
care of the participant;
3. An
enrollment agreement and date of the participant's first visit;
4. If applicable, documented general consent
and informed consent by the participant or the participant's
representative;
5. If applicable,
the name and contact information of the participant's representative and:
a. The document signed by the participant
consenting for the participant's representative to act on the participant's
behalf; or
b. If the participant'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 attorney or mental health care power of
attorney; or
ii. Is a legal
guardian, a copy of the court order establishing guardianship;
6. Documentation of medical history;
7. A
copy of the participant's health care directive, if applicable;
8.
Orders;
9. The medical assessment required in
R9-10-1107(D);
10. A care plan;
11. The comprehensive
assessment required in R9-10-1107(F);
12. Progress
notes;
13. If applicable,
documentation of any actions taken to control the participant's sudden,
intense, or out-of-control behavior to prevent harm to the participant or
another individual;
14. Documentation of adult day health services
provided to the participant;
15. The disposition of
the participant upon discharge;
16. The discharge
date, if applicable;
17. Documentation of a medication administered to the
participant that includes:
a. The date and
time of administration;
b. The
name, strength, dosage, and route of administration;
c. The identification and signature of the
individual administering, providing assistance in the self-administration of
medication, or observing the participant's self-administration of the
medication;
d. If medication for
pain is administered on a PRN basis to a participant:
i. An identification of the participant's
pain before administering the medication, and
ii. The effect of the medication
administered; and
e. Any
adverse reaction a participant has to the medication;
18.
If applicable, documentation of:
a. A
significant change in the participant's condition,
b. An injury or accident that occurred at the
adult day health care facility and required medical services, and
c. Notification provided to the participant's
medical practitioner or the participant's representative of the significant
change in subsection (C)(18)(a) or the injury or accident in subsection
(C)(18)(b);
19. Documentation of
whether the participant may sign in or out of the adult day health care
facility;
20. Documentation of freedom from infectious
tuberculosis required in R9-10-1107(A); and
21. Names and
telephone numbers of individuals to be notified in the event of an
emergency.
Disclaimer: These regulations may not be the most recent version. Arizona may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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