R9-10-910. Medical Records

A. An administrator shall ensure that: 1. A medical record is established and maintained for a 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 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 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 the medical staff member 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 the 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 an outpatient surgical center 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 date of birth; and d. Any known allergies, including medication allergies; 2. The admitting medical practitioner; 3. An admitting diagnosis; 4. Documentation of general consent and informed consent for treatment by the patient or the patient’s representative, except in an emergency; 5. 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; 6. The date of admission and, if applicable, date of discharge; 7. Documentation of medical history and results of a physical examination; 8. A copy of patient’s health care directive, if applicable; 9. Orders; 10. Progress notes; 11. 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; 12. Documentation of outpatient surgical center services provided to the patient; 13. A discharge summary, if applicable; 14. Documentation of receipt of written discharge instructions by the patient or patient’s representative; 15. If applicable: a. Laboratory reports, b. Radiologic report, and c. Diagnostic reports; 16. The anesthesia report, required in R9-10-911(C)(2); 17. The operative report of the surgical procedure, required in R9-10-911(C)(1); and 18. 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: 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: 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 or observing the self-administration of the medication; and f. Any adverse reaction a patient has to the medication.