Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING
Article 18 - ADULT BEHAVIORAL HEALTH THERAPEUTIC HOMES
Section R9-10-1807 - Medical Records

Universal Citation: AZ Admin Code R 9-10-1807

Current through Register Vol. 30, No. 38, September 20, 2024

A. A provider 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. Only recorded by the provider or individual designated by the provider to record an entry;

b. Dated, legible, and authenticated; and

c. Not changed to make the initial entry illegible;

3. A resident's medical record is available to an individual:
a. Authorized by policies and procedures to access the resident's medical record;

b. If the individual is not authorized according to policies and procedures, with the written consent of the resident or the resident's representative; or

c. As permitted by law; and

4. A resident's medical record is protected from loss, damage, or unauthorized use.

B. If a provider maintains residents' medical records electronically, the provider shall ensure that safeguards exist to prevent unauthorized access.

C. A provider 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,

c. Any known allergies, and

d. Medication information for the resident;

2. The names, addresses, and telephone numbers of:
a. The resident's medical practitioner;

b. The resident's case manager, if applicable;

c. The behavioral health professional assigned to the resident by the adult behavioral health therapeutic home's collaborating health care institution; and

d. An individual to be contacted in the event of an emergency;

3. The date of the resident's acceptance by the adult behavioral health therapeutic home and, if applicable, the date of the resident's release from the adult behavioral health therapeutic home;

4. 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 attorney or mental health care power of attorney; or

ii. Is a legal guardian, a copy of the court order establishing guardianship;

5. A copy of the resident's treatment plan and any updates to the resident's treatment plan, obtained from the adult behavioral health therapeutic home's collaborating health care institution;

6. For a resident receiving assistance in the self-administration of medication, documentation that includes for each medication:
a. The date and time of assistance;

b. The name, strength, dosage, and route of administration;

c. The provider's signature or first and last initials; and

d. Any adverse reaction the resident has to the medication;

7. Documentation of the resident's refusal of a medication, if applicable;

8. Documentation of any significant change in a resident's behavior or physical, cognitive, or functional condition and the action taken by a provider to address the resident's changing needs;

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

10. If applicable, a written notice of termination of residency.

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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