R9-10-411. Medical Records

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 comply with A.R.S. § 36-420; 15. 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; 16. If applicable, documentation that evacuation from the nursing care institution would cause harm to the resident; 17. The disposition of the resident after discharge; 18. The discharge plan; 19. The discharge summary; 20. Transfer documentation; 21. If applicable: a. A laboratory report, b. A radiologic report, c. A diagnostic report, and d. A consultation report; 22. Documentation of freedom from infectious tuberculosis required in R9-10-407(7); 23. 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; 24. 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 25. If applicable, a copy of written notices, including follow- up instructions, provided to the resident or the resident’s representative.