1. A. An administrator shall ensure that:

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

   2. 2. An entry in a participant’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 participant’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 participant’s medical record is available to an individual:

      1. a. Authorized according to policies and procedures to access the participant’s medical record;
      2. b. If the individual is not authorized according to policies and procedures, with the written consent of the participant or the participant’s representative; or
      3. c. As permitted by law; and
   6. 6. A participant’s medical record is protected from loss, damage, or unauthorized use.

2. B. If a substance abuse transitional agency maintains participants’ 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 participant’s medical record contains:

   1. 1. Participant information that includes:

      1. a. The participant’s name;
      2. b. The participant’s address;
      3. c. The participant’s date of birth; and
      4. d. Any known allergies, including medication allergies;
   2. 2. A participant’s presenting behavioral health issue;
   3. 3. Documentation of general consent and, if applicable, informed consent for treatment by the participant or the participant’s representative, except in an emergency;

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

      1. a. The document signed by the participant consenting for the participant’s representative to act on the participant’s behalf; or

      2. b. If the participant’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 results of a physical examination;
   6. 6. The date of admission and, if applicable, date of discharge;
   7. 7. Orders;
   8. 8. Assessment;
   9. 9. Progress notes;
   10. 10. Documentation of substance abuse transitional agency services provided to the participant;
   11. 11. If applicable, documentation of any actions taken to control the participant’s sudden, intense, or out-of-control behavior to prevent harm to the participant or another individual;
   12. 12. The disposition of the participant upon discharge;
   13. 13. The discharge plan;
   14. 14. A discharge summary, if applicable; and

   15. 15. Documentation of a medication administered to a participant 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 evaluation of the participant’s pain before administering the medication, and
          2. ii. The effect of the medication administered;

       4. d. For a psychotropic medication:

          1. i. An evaluation of the participant’s behavior before administering the psychotropic medication, and
          2. ii. The effect of the psychotropic medication administered;
       5. e. The signature of the individual administering the medication; and
       6. f. Any adverse reaction a participant has to the medication.

Historical Note

Adopted effective February 1, 1994 (Supp. 94-1). Section repealed; new Section made by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Section R9-10-1410 renumbered to R9-10-1409; new Section R9-10-1410 renumbered from R9-10-1411 and amended by exempt rulemaking at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2).