R9-10-811. Medical Records

A. A manager 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. Only recorded 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. 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; 4. 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; and 5. A resident’s medical record is protected from loss, damage, or unauthorized use. B. If an assisted living facility maintains residents’ medical records electronically, a manager 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. A manager shall ensure that a resident’s medical record contains: 1. Resident information that includes: a. The resident’s name, and b. The resident’s date of birth; 2. The names, addresses, and telephone numbers of: a. The resident’s primary care provider; b. Other persons, such as a home health agency or hospice service agency, involved in the care of the resident; and c. An individual to be contacted in the event of an emergency, significant change in the resident’s condition, or termination of residency; 3. 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; 4. The date of acceptance and, if applicable, the date of termination of residency; 5. Documentation of the resident’s needs required in R9-10- 807(B); 6. Documentation of general consent and informed consent, if applicable; 7. Except as allowed in R9-10-808(B)(2), documentation of freedom from infectious tuberculosis as required in R9- 10-807(A); 8. A copy of the resident’s health care directive, if applicable; 9. The resident’s signed residency agreement and any amendments; 10. Resident’s service plan and updates; 11. Documentation of assisted living services provided to the resident; 12. A medication order from a medical practitioner for each medication that is administered to the resident or for which the resident receives assistance in the self-administration of the medication; 13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes: a. The date and time of administration or assistance; b. The name, strength, dosage, and route of administration; c. The name and signature of the individual administering or providing assistance in the self-administration of medication; and d. An unexpected reaction the resident has to the medication; 14. Documentation of the resident’s refusal of a medication, if applicable; 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 of a determination by a medical practitioner that evacuation from the assisted living facility during an evacuation drill would cause harm to the resident; 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d); 18. Documentation of the resident’s orientation to exits from the assisted living facility required in R9-10-819(B); 19. If a resident is receiving behavioral health services other than behavioral care, documentation of the determination in R9-10-813(3); 20. If a resident is receiving behavioral care, documentation of the determination in R9-10-812(3); 21. If applicable, for a resident who is unable to direct self- care, the information required in R9-10-815(F); 22. Documentation of any significant change in a resident’s behavior, physical, cognitive, or functional condition and the action taken by a manager or caregiver to address the resident’s changing needs; 23. Documentation of the notification required in R9-10- 803(G) if the resident is incapable of handling financial affairs; and 24. If the resident no longer resides and receives assisted living services from the assisted living facility: a. A written notice of termination of residency; or b. If the resident terminated residency, the date the resident terminated residency.