Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING
Article 7 - BEHAVIORAL HEALTH RESIDENTIAL FACILITIES
Section R9-10-712 - Medical Records

Universal Citation: AZ Admin Code R 9-10-712

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 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 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 according to 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;

6. Policies and procedures include the maximum time-frame to retrieve a resident's medical record at the request of a medical practitioner, behavioral health professional, or authorized personnel member; and

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

B. If a behavioral health residential facility 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 address;

c. The resident's date of birth; and

d. Any known allergies, including medication allergies;

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

3. An admitting diagnosis or presenting behavioral health issues;

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

5. If applicable, the name and contact information of the resident's representative and:
a. If the resident is 18 years of age or older or an emancipated minor, 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. If applicable, documented general consent and informed consent for treatment by the resident or the resident's representative;

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

8. A copy of resident's health care directive, if applicable;

9. Orders;

10. If applicable, documentation that evaluation or treatment was ordered by a court according to A.R.S. Title 36, Chapter 5 or A.R.S. § 8-341.01;

11. Assessment;

12. Treatment plans;

13. Interval notes;

14. Progress notes;

15. Documentation of behavioral health services and physical health services provided to the resident;

16. If applicable, documentation of the use of an emergency safety response;

17. If applicable, documentation of time-out required in R9-10-714(6);

18. Except as allowed in R9-10-707(E)(1)(d), documentation of freedom from infectious tuberculosis required in R9-10-707(A)(13);

19. The disposition of the resident after discharge;

20. The discharge plan;

21. The discharge summary, if applicable;

22. If applicable:
a. Laboratory reports,

b. Radiologic reports,

c. Diagnostic reports, and

d. Consultation reports; and

23. Documentation of medication administered to the resident 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, when administered initially or on a PRN basis:
i. An assessment of the resident's pain before administering the medication, and

ii. The effect of the medication administered;

d. For a psychotropic medication, when administered initially or on a PRN basis:
i. An assessment of the resident's behavior before administering the psychotropic medication, and

ii. The effect of the psychotropic medication administered;

e. The identification, signature, and professional designation of the individual administering or providing assistance in the self-administration of the medication; and

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

The following Section was adopted under an exemption from the provisions of the Administrative Procedure Act which means these rules were not reviewed by the Governor's Regulatory Review Council; the Department did not submit notice of proposed rulemaking to the Secretary of State for publication in the Arizona Administrative Register; and the Department was not required to hold public hearings on these rules (Supp. 98-4).

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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