Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING
Article 9 - OUTPATIENT SURGICAL CENTERS
Section R9-10-910 - Medical Records

Universal Citation: AZ Admin Code R 9-10-910

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 a 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 member according to policies and procedures; and

c. If the order is a verbal order, authenticated by the medical staff member 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 an outpatient surgical 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, including medication allergies;

2. The admitting medical practitioner;

3. An admitting diagnosis;

4. Documentation of general consent and informed consent for treatment by the patient or the patient's representative, except in an emergency;

5. 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;

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

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

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

9. Orders;

10. Progress notes;

11. 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;

12. Documentation of outpatient surgical center services provided to the patient;

13. A discharge summary, if applicable;

14. Documentation of receipt of written discharge instructions by the patient or patient's representative;

15. If applicable:
a. Laboratory reports,

b. Radiologic report, and

c. Diagnostic reports;

16. The anesthesia report, required in R9-10-911(C)(2);

17. The operative report of the surgical procedure, required in R9-10-911(C)(1); and

18. 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:
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:
i. An assessment of the patient'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 observing the self-administration of the medication; and

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

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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