R9-10-213. Medical Records

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 staff member according to policies and procedures; and c. If the order is a verbal order, authenticated by a medical staff member or medical practitioner; 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 personnel members and medical staff members authorized by policies and procedures to access the medical record; 6. Policies and procedures include the maximum time-frame to retrieve an onsite or off-site patient’s medical record at the request of a medical staff member or authorized personnel member; and 7. A patient’s medical record is protected from loss, damage, or unauthorized use. B. If a hospital 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 medical record for an inpatient 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 or sensitivities; 2. Medication information that includes: a. A medication ordered for the patient; and b. A medication administered to the patient including: i. The date and time of administration; ii. The name, strength, dosage, amount, and route of administration; iii. The identification and authentication of the individual administering the medication; and iv. Any adverse reaction the patient has to the medication; 3. Documentation of general consent and, if applicable, informed consent for treatment by the patient or the patient’s representative, except in an emergency; 4. A medical history and results of a physical examination or an interval note; 5. If the patient provides a health care directive, the health care directive signed by the patient; 6. An admitting diagnosis; 7. The date of admission and, if applicable, the date of discharge; 8. Names of the admitting medical staff member and medical practitioners coordinating the patient’s care; 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. 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; 10. Orders; 11. Care plans; 12. Documentation of hospital services provided to the patient; 13. Progress notes; 14. The disposition of the patient after discharge; 15. Discharge planning, including discharge instructions required in R9-10-209(B)(3); 16. A discharge summary; and 17. If applicable: a. A laboratory report, b. A pathology report, c. An autopsy report, d. A radiologic report, e. A diagnostic imaging report, f. Documentation of restraint or seclusion, and g. A consultation report. D. An administrator shall ensure that a hospital’s medical record for an outpatient contains: 1. Patient information that includes: a. The patient’s name; b. The patient’s address; c. The patient’s date of birth; d. The name and contact information of the patient’s representative, if applicable; and e. Any known allergy including medication allergies or sensitivities; 2. If necessary for treatment, medication information that includes: a. A medication ordered for the patient; and b. A medication administered to the patient including: i. The date and time of administration; ii. The name, strength, dosage, amount, and route of administration; iii. The identification and authentication of the individual administering the medication; and iv. Any adverse reaction the patient has to the medication; 3. Documentation of general and, if applicable, informed consent for treatment by the patient or the patient’s representative, except in an emergency; 4. An admitting diagnosis or reason for outpatient medical services; 5. Orders; 6. Documentation of hospital services provided to the patient; and 7. If applicable: a. A laboratory report, b. A pathology report, c. An autopsy report, d. A radiologic report, e. A diagnostic imaging report, f. Documentation of restraint or seclusion, and g. A consultation report. E. In addition to the requirements in subsection (D), an administrator shall ensure that the hospital’s record of emergency services provided to a patient contains: 1. Documentation of treatment the patient received before arrival at the hospital, if available; 2. The patient’s medical history; 3. An assessment, including the name of the individual performing the assessment; 4. The patient’s chief complaint; 5. The name of the individual who treated the patient in the emergency room, if applicable; and 6. The disposition of the patient after discharge.