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 facility 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 facility 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 the 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. A patient’s medical record is available to the patient or patient’s representative upon request at a time agreed upon by the patient or patient’s representative and the administrator; and
   7. 7. A patient’s medical record is protected from loss, damage, or unauthorized use.

2. B. If a behavioral health specialized transitional facility maintains patient’s 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. A copy of the court order requiring the patient to be detained at or committed to the behavioral health specialized transitional facility;
   2. 2. The date the patient was detained at or committed to the behavioral health specialized transitional facility;

   3. 3. Patient information that includes:

      1. a. The patient’s name;
      2. b. The patient’s address;
      3. c. The patient’s date of birth; and
      4. d. Any known allergies, including medication allergies;
   4. 4. Documentation of the patient’s freedom from infectious tuberculosis as required in R9-10-1306(C)(2);
   5. 5. Documentation of general consent and, if applicable, informed consent for treatment by the patient or the patient’s representative, except in an emergency;

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

      1. a. 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;
   7. 7. Documentation of medical history and physical examination of the patient;
   8. 8. A copy of patient’s health care directives, if applicable;
   9. 9. Orders;
   10. 10. The patient’s assessment including updates;
   11. 11. The patient’s treatment plan including updates;
   12. 12. Progress notes;
   13. 13. Documentation of transportation provided to the patient;
   14. 14. Documentation of behavioral health services and physical health services provided to the patient;
   15. 15. Documentation of patient’s annual examination and report required by A.R.S. § 36-3708;

   16. 16. Documentation of the annual written notice of the patient of the patient’s right to petition for:

       1. a. Conditional release to a less restrictive alternative as required by A.R.S. § 36-3709, or
       2. b. Discharged as required by A.R.S. § 36-3714;
   17. 17. A copy of any petition for discharge or conditional release to a less restrictive alternative filed by the patient and provided to the behavioral health specialized transitional facility and the outcome of the petition;

   18. 18. Documentation of the patient’s, if applicable;

       1. a. Conditional release to a less restrictive alternative; or
       2. b. Discharge, including the disposition of the patient upon discharge;

   19. 19. If a patient has been discharged, a discharge summary that includes:

       1. a. A summary of the treatment provided to the patient;
       2. b. The patient’s progress in meeting treatment goals, including treatment goals that were and were not achieved;
       3. c. The name, dosage, and frequency of each medication for the patient ordered at the time of the patient’s discharge from the behavioral health specialized transitional facility;
       4. d. A description of the disposition of the patient’s possessions, funds, or medications; and
       5. e. The date the patient was discharged from the behavioral health specialized transitional facility;

   20. 20. If applicable:

       1. a. Laboratory reports,
       2. b. Radiologic reports,
       3. c. Diagnostic reports,
       4. d. Documentation of restraint or seclusion,
       5. e. Patient follow-up instructions, and
       6. f. Consultation reports; and

   21. 21. 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;

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

          c For a medication administered for pain:

       3. 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;
       4. e. The identification, signature, and professional designation of the individual administering or observing the self-administration of the medication;
       5. f. Any adverse reaction a patient has to the medication; and
       6. g. If applicable, a patient’s refusal to take medication ordered for the patient.

Historical Note

Emergency rule adopted effective November 29, 1991, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 91-4). Emergency rule adopted again effective February 28, 1992, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 92-1). Emergency rule adopted again effective May 28, 1992, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 92-2). Emergency rule adopted again effective August 27, 1992, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 92-3). Adopted with changes effective November 25, 1992 (Supp. 92-4). Section R9-10-1312 repealed effective November 1, 1998, under an exemption from the provisions of the Administrative Procedure Act pursuant to Laws 1998, Ch. 178, § 17; filed with the Office of the Secretary of State October 2, 1998 (Supp. 98-4). New 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 expedited rulemaking at 24 A.A.R. 2764, effective September 11, 2018 (Supp. 18-3).