Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING
Article 21 - RECOVERY CARE CENTERS
Section R9-10-2111 - Medical Records

Universal Citation: AZ Admin Code R 9-10-2111

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

A. An administrator shall ensure that:

1. A patient's 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 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 medical staff according to policies and procedures; and

c. If the order is a verbal order, authenticated by the medical staff 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 an individual:
a. Authorized according by policies and procedures to access the patient's medical record;

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

c. As permitted by law;

6. Policies and procedures that include the maximum time-frame to retrieve an onsite or off-site patient's medical record at the request of a medical staff or authorized personnel member; and

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

B. If a recovery care center 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,

c. The patient's date of birth, and

d. Any known allergies;

2. The date of admission and, if applicable, the date of discharge;

3. The admitting diagnosis;

4. A discharge summary from the referring health care institution or physician;

5. If applicable, documented general consent and informed consent by the patient or the patient's representative;

6. The medical history and physical examination required in R9-10-2107(B)(1);

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

8. The name and telephone number of the patient's medical practitioner;

9. 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;

10. Orders;

11. Nursing assessment;

12. Treatment plans;

13. Progress notes;

14. Documentation of recovery care center services provided to a patient;

15. The disposition of the patient after discharge;

16. The discharge plan;

17. A discharge summary, if applicable;

18. Transfer documentation from the referring health care institution or physician;

19. If applicable:
a. A laboratory report,

b. A radiologic report,

c. A diagnostic report, and

d. A consultation report;

20. 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;

21. If applicable, documentation that evacuation from the recovery care center would cause harm to the patient; and

22. 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 on a PRN basis:
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 administered on a PRN basis:
i. An assessment of the patient's behavior before administering the psychotropic medication, and

ii. The effect of the psychotropic medication administered;

e. The signature of the individual administering or observing the patient self-administer the medication; and

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

D. An administrator shall ensure that a patient's medical record is completed within 30 calendar days after the patient's discharge.

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.