1. A. An administrator shall ensure that:

   1. 1. A medical record is established and maintained for each patient according to A.R.S. Title 12, Chapter 13, Article 7.1;

   2. 2. An entry in a patient’s medical record is:

      1. a. Recorded only by a personnel member authorized by policies and procedures to make the entry;
      2. b. Dated, legible, and authenticated; and
      3. c. Not changed to make the initial entry illegible;

   3. 3. An order is:

      1. a. Dated when the order is entered in the patient’s medical record and includes the time of the order;
      2. b. Authenticated by a medical practitioner or behavioral health professional according to policies and procedures; and
      3. c. If the order is a verbal order, authenticated by the medical practitioner or behavioral health professional issuing the order;
   4. 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. 5. A patient’s medical record is available to an individual:

      1. a. Authorized according to policies and procedures to access the patient’s medical record;
      2. 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
      3. c. As permitted by law;
   6. 6. Policies and procedures include the maximum time-frame to retrieve a patient’s medical record at the request of a medical practitioner, behavioral health professional, or authorized personnel member; and
   7. 7. A patient’s medical record is protected from loss, damage, or unauthorized use.

2. B. If an outpatient treatment center maintains patients’ medical records electronically, an administrator shall ensure that:

   1. 1. Safeguards exist to prevent unauthorized access, and
   2. 2. The date and time of an entry in a medical record is recorded by the computer’s internal clock.

3. C. An administrator shall ensure that a patient’s medical record contains:

   1. 1. Patient information that includes:

      1. a. Except as specified in A.A.C. R9-6-1005, the patient’s name and address;
      2. b. The patient’s date of birth; and
      3. c. Any known allergies, including medication allergies;
   2. 2. A diagnosis or reason for outpatient treatment center services;
   3. 3. Documentation of general consent and, if applicable, informed consent for treatment by the patient or the patient’s representative, except in an emergency;

   4. 4. If applicable, the name and contact information of the patient’s representative and:

      1. 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

      2. b. If the patient’s representative:

         1. 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
         2. ii. Is a legal guardian, a copy of the court order establishing guardianship;
   5. 5. Documentation of medical history and, if applicable, results of a physical examination;
   6. 6. Orders;
   7. 7. Assessment;
   8. 8. Treatment plans;
   9. 9. Interval notes;
   10. 10. Progress notes;
   11. 11. Documentation of outpatient treatment center services provided to the patient;
   12. 12. The name of each individual providing treatment or a diagnostic procedure;
   13. 13. Disposition of the patient upon discharge;
   14. 14. Documentation of the patient’s follow-up instructions provided to the patient;
   15. 15. A discharge summary;

   16. 16. If applicable:

       1. a. Laboratory reports,
       2. b. Radiologic reports,
       3. c. Sleep disorder reports,
       4. d. Diagnostic reports, and
       5. e. Consultation reports;
   17. 17. 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, other than actions taken while providing behavioral health observation/stabilization services; and

   18. 18. Documentation of a medication administered to the patient that includes:

       1. a. The date and time of administration;
       2. b. The name, strength, dosage, and route of administration;

       3. c. For a medication administered for pain:

          1. i. An assessment of the patient’s pain before administering the medication, and
          2. ii. The effect of the medication administered;

       4. d. For a psychotropic medication:

          1. i. An assessment of the patient’s behavior before administering the psychotropic medication, and
          2. ii. The effect of the psychotropic medication administered;
       5. e. The identification, signature, and professional designation of the individual administering or observing the self-administration of the medication;
       6. f. Any adverse reaction a patient has to the medication; and
       7. g. For prepacked or sample medication provided to the patient for self-administration, the name, strength, dosage, amount, route of administration, and expiration date.

Historical Note

New Section made by final rulemaking at 14 A.A.R. 294, effective March 8, 2008 (Supp. 08-1). Section amended by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2).