Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING
Article 12 - HOME HEALTH AGENCIES
Section R9-10-1209 - Medical Records

Universal Citation: AZ Admin Code R 9-10-1209

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 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 an individual authorized by a 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 medical record and includes the time of the order;

b. Authenticated by a physician, registered nurse practitioner, or podiatrist according to policies and procedures; and

c. If the order is a verbal order, authenticated by the physician, registered nurse practitioner, or podiatrist issuing the order;

4. 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 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 members, physicians, registered nurse practitioners, or podiatrists authorized by policies and procedures to access the patient's medical record;

6. Information in a patient's medical record is disclosed to an individual not authorized under subsection (A)(5) only with the written consent of a patient or the patient's representative or as permitted by law; and

7. A patient's medical record is protected from loss, damage, or unauthorized use.

B. If a home health agency 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 patient's medical record contains:

1. Patient information that includes:
a. The patient's name;

b. The patient's address and telephone number;

c. The patient's date of birth; and

d. Any known allergies, including medication allergies;

2. The date the patient began receiving services from the home health agency and, if applicable, the date the patient stopped receiving services from the home health agency;

3. The name and telephone of the patient's physician or registered nurse practitioner;

4. The name and telephone number of patient's podiatrist, if applicable;

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

6. Documentation of medical history and current diagnoses;

7. A copy of patient's health care directive, if applicable;

8. 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 emancipated 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 attorney or mental health care power of attorney;

9. Orders;

10. Assessments;

11. Care plan;

12. Progress notes;

13. If applicable, documentation of any actions taken to control the patient's sudden, intense or out-of-control behavior to prevent harm to the patient or another individual;

14. Documentation of meetings with the patient to assess the home health services and supportive services provided to the patient;

15. The disposition of the patient upon discharge;

16. The discharge plan;

17. Discharge instructions and discharge summary, if applicable;

18. If applicable:
a. Laboratory reports,

b. Radiologic reports,

c. Diagnostic reports, and

d. Consultation reports;

19. 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 administration;

c. For a medication administered for pain:
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:
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 designation of the individual administering or observing the self-administration of the medication; and

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

20. Documentation of tasks assigned to a home health aide or other personnel member;

21. Documentation of coordination of patient care;

22. Copies of patient summary reports sent to the patient's physician, registered nurse practitioner, or podiatrist, as applicable; and

23. Documentation of contacts with the patient's physician, registered nurse practitioner, or podiatrist, as applicable, by a personnel member or the patient.

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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