R9-10-611. Medical Records

A. An administrator shall ensure that: 1. A patient’s 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 practitioner according to policies and procedures; and c. If the order is a verbal order, authenticated by the medical practitioner 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 a 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 a hospice 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 telephone number, d. The patient’s date of birth, and e. Any known allergy; 2. The admission date and, if applicable, the date that the patient stopped receiving services from the hospice; 3. The name and telephone number of the patient’s physician; 4. 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. Is a legal guardian, a copy of the court order establishing guardianship; or ii. 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; 5. The admitting diagnosis; 6. If applicable, documented general consent and informed consent, by the patient or the patient’s representative; 7. Documentation of medical history; 8. A copy of the patient’s living will, health care power of attorney, or other health care directive, if applicable; 9. Orders; 10. The assessment required in R9-10-607(B)(1); 11. Care plans; 12. Progress notes for each patient contact, including: a. The date of the patient contact, b. The services provided, c. A description of the patient’s condition, and d. Instructions given to the patient or patient’s representative; 13. Documentation of hospice services provided to the patient; 14. 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; 15. Documentation of coordination of patient care; 16. Documentation of contacts with the patient’s physician by a personnel member; 17. The discharge summary, if applicable; 18. If applicable, transfer documentation from a sending health care institution; and 19. 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, when initially administered or when administered on a PRN basis: 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, when initially administered or when administered on a PRN basis: 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 the medication; and f. Any adverse reaction a patient has to the medication.