Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING
Article 3 - BEHAVIORAL HEALTH INPATIENT FACILITIES
Section R9-10-312 - Medical Records

Universal Citation: AZ Admin Code R 9-10-312

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 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 patient'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 patient's medical record is available to an individual:
a. Authorized according to 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; and

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

B. If a behavioral health inpatient facility 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 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 allergy, including medication allergies;

2. Medication information that includes:
a. Documentation of medication ordered for the patient; and

b. Documentation of medication administered to the patient that includes:
i. The date and time of administration;

ii. The name, strength, dosage, amount, and route of administration;

iii. For a medication administered for pain on a PRN basis:
(1) An assessment of the patient's pain before administering the medication, and

(2) The effect of the medication administered;

iv. For a psychotropic medication administered on a PRN basis:
(1) An assessment of the patient's behavior before administering the psychotropic medication, and

(2) The effect of the psychotropic medication administered;

v. The identification and authentication of the individual administering the medication or providing assistance in the self-administration of the medication; and

vi. Any adverse reaction the patient has to the medication;

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

4. 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. 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. The patient's medical history and results of a physical examination or an interval note;

6. If the patient provides a health care directive, the health care directive signed by the patient or the patient's representative;

7. An admitting diagnosis or presenting symptoms;

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

9. The name of the admitting medical practitioner or behavioral health professional;

10. Orders;

11. The patient's nursing assessment and behavioral health assessment and any interval notes;

12. Treatment plans;

13. Documentation of behavioral health services and physical health services provided to the patient;

14. Progress notes;

15. If applicable, documentation of restraint or seclusion;

16. If applicable, documentation that evacuation from the behavioral health inpatient facility would cause harm to the patient;

17. The disposition of the patient after discharge;

18. The discharge plan;

19. The discharge summary; and

20. If applicable:
a. A laboratory report,

b. A radiologic report,

c. A diagnostic report, and

d. A consultation report.

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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