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 an individual authorized by policies and procedures to make the entry;
      2. b. Dated, timed, 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 physician, registered nurse practitioner, or podiatrist according to policies and procedures; and
      3. c. If the order is a verbal order, authenticated by the physician, registered nurse practitioner, or podiatrist 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 personnel members, physicians, registered nurse practitioners, or podiatrists authorized by policies and procedures to access the patient’s medical record;
   6. 6. Information in a patient’s medical record is disclosed to an individual not authorized under subsection (A)(5) only with the written consent of a patient or the patient’s representative or as permitted by law; and
   7. 7. A patient’s medical record is protected from loss, damage, or unauthorized use.

2. B. If a home health agency 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 patient’s 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. The patient’s name;
      2. b. The patient’s address and telephone number;
      3. c. The patient’s date of birth; and
      4. d. Any known allergies, including medication allergies;
   2. 2. The date the patient began receiving services from the home health agency and, if applicable, the date the patient stopped receiving services from the home health agency;
   3. 3. The name and telephone of the patient’s physician or registered nurse practitioner;
   4. 4. The name and telephone number of patient’s podiatrist, if applicable;
   5. 5. Documentation of general consent and, if applicable, informed consent;
   6. 6. Documentation of medical history and current diagnoses;
   7. 7. A copy of the patient’s health care directive, if applicable;

   8. 8. 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. Is a legal guardian, a copy of the court order establishing guardianship; or
         2. 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;
   9. 9. Orders;
   10. 10. Assessments;
   11. 11. Care plan;
   12. 12. Progress notes;
   13. 13. 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;
   14. 14. Documentation of meetings with the patient to assess the home health services and supportive services provided to the patient;
   15. 15. The disposition of the patient upon discharge;
   16. 16. The discharge plan;
   17. 17. Discharge instructions and discharge summary, if applicable;

   18. 18. If applicable:

       1. a. Laboratory reports,
       2. b. Radiologic reports,
       3. c. Diagnostic reports, and
       4. d. Consultation reports;

   19. 19. 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; and
       6. f. Any adverse reaction a patient has to the medication;
   20. 20. Documentation of tasks assigned to a home health aide or other personnel member;
   21. 21. Documentation of coordination of patient care;
   22. 22. Copies of patient summary reports sent to the patient’s physician, registered nurse practitioner, or podiatrist, as applicable; and
   23. 23. Documentation of contacts with the patient’s physician, registered nurse practitioner, or podiatrist, as applicable, by a personnel member or the patient.

Historical Note

Section made 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). Amended by final rulemaking at 31 A.A.R. 651 (February 28, 2025), effective April 6, 2025 (Supp. 25-1).