R9-10-712. 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 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.