Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING
Article 4 - NURSING CARE INSTITUTIONS
Section R9-10-411 - Medical Records

Universal Citation: AZ Admin Code R 9-10-411

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 resident according to A.R.S. Title 12, Chapter 13, Article 7.1;

2. An entry in a resident'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 resident'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 resident's medical record is available to an individual:
a. Authorized to access the resident's medial record according to policies and procedures;

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

c. As permitted by law; and

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

B. If a nursing care institution maintains residents' 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 resident's medical record is recorded by the computer's internal clock.

C. An administrator 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; and

c. Any known allergies, including medication allergies;

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

3. The admitting diagnosis or presenting symptoms;

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

5. 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;

6. The medical history and physical examination required in R9-10-407(6);

7. A copy of the resident's living will or other health care directive, if applicable;

8. The name and telephone number of the resident's attending physician;

9. Orders;

10. Care plans;

11. Behavioral care plans, if the resident is receiving behavioral care;

12. Documentation of nursing care institution services provided to the resident;

13. Progress notes;

14. 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;

15. If applicable, documentation that evacuation from the nursing care institution would cause harm to the resident;

16. The disposition of the resident after discharge;

17. The discharge plan;

18. The discharge summary;

19. Transfer documentation;

20. If applicable:
a. A laboratory report,

b. A radiologic report,

c. A diagnostic report, and

d. A consultation report;

21. Documentation of freedom from infectious tuberculosis required in R9-10-407(7);

22. Documentation of a medication administered to the resident that includes:
a. The date and time of administration;

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

c. The type of vaccine, if applicable;

d. For a medication administered for pain on a PRN basis:
i. An evaluation of the resident's pain before administering the medication, and

ii. The effect of the medication administered;

e. For a psychotropic medication administered on a PRN basis:
i. An evaluation of the resident's symptoms before administering the psychotropic medication, and

ii. The effect of the psychotropic medication administered;

f. The identification, signature, and professional designation of the individual administering the medication; and

g. Any adverse reaction a resident has to the medication;

23. If the resident has been assessed for receiving nutrition and feeding assistance from a nutrition and feeding assistant, documentation of the assessment and the determination of eligibility; and

24. If applicable, a copy of written notices, including follow-up instructions, provided to the resident or the resident's representative.

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.