Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING
Article 14 - SUBSTANCE ABUSE TRANSITIONAL FACILITIES
Section R9-10-1410 - Medical Records

Universal Citation: AZ Admin Code R 9-10-1410

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 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 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 participant's medical record and includes the time of the order;

b. Authenticated by a medical practitioner or behavioral health professional according to policies and procedures; and

c. If the order is a verbal order, authenticated by the medical practitioner or behavioral health professional 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 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

6. A participant's medical record is protected from loss, damage, or unauthorized use.

B. If a substance abuse transitional agency maintains participants' 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 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. A participant's presenting behavioral health issue;

3. Documentation of general consent and, if applicable, informed consent for treatment by the participant or the participant's representative, except in an emergency;

4. 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;

5. Documentation of medical history and results of a physical examination;

6. The date of admission and, if applicable, date of discharge;

7. Orders;

8. Assessment;

9. Progress notes;

10. Documentation of substance abuse transitional agency services provided to the participant;

11. 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;

12. The disposition of the participant upon discharge;

13 The discharge plan;

14A discharge summary, if applicable; and

15.Documentation of a medication administered to a participant 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 evaluation of the participant's pain before administering the medication, and

ii. The effect of the medication administered;

d. For a psychotropic medication:
i. An evaluation of the participant's behavior before administering the psychotropic medication, and

ii. The effect of the psychotropic medication administered;

e. The signature of the individual administering the medication; and

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

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.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.