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 staff member according to policies and procedures; and
      3. c. If the order is a verbal order, authenticated by a medical staff member or medical practitioner;
   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 and medical staff members authorized by policies and procedures to access the medical record;
   6. 6. Policies and procedures include the maximum time-frame to retrieve an onsite or off-site patient’s medical record at the request of a medical staff member or authorized personnel member; and
   7. 7. A patient’s medical record is protected from loss, damage, or unauthorized use.

2. B. If a hospital 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 medical record for an inpatient contains:

   1. 1. 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 allergy, including medication allergies or sensitivities;

   2. 2. Medication information that includes:

      1. a. A medication ordered for the patient; and

      2. b. A medication administered to the patient including:

         1. i. The date and time of administration;
         2. ii. The name, strength, dosage, amount, and route of administration;
         3. iii. The identification and authentication of the individual administering the medication; and
         4. iv. Any adverse reaction the patient has to the medication;
   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. A medical history and results of a physical examination or an interval note;
   5. 5. If the patient provides a health care directive, the health care directive signed by the patient;
   6. 6. An admitting diagnosis;
   7. 7. The date of admission and, if applicable, the date of discharge;
   8. 8. Names of the admitting medical staff member and medical practitioners coordinating the patient’s care;

   9. 9. 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;
   10. 10. Orders;
   11. 11. Care plans;
   12. 12. Documentation of hospital services provided to the patient;
   13. 13. Progress notes;
   14. 14. The disposition of the patient after discharge;
   15. 15. Discharge planning, including discharge instructions required in R9-10-209(B)(3);
   16. 16. A discharge summary; and

   17. 17. If applicable:

       1. a. A laboratory report,
       2. b. A pathology report,
       3. c. An autopsy report,
       4. d. A radiologic report,
       5. e. A diagnostic imaging report,
       6. f. Documentation of restraint or seclusion, and
       7. g. A consultation report.

4. D. An administrator shall ensure that a hospital’s medical record for an outpatient contains:

   1. 1. Patient information that includes:

      1. a. The patient’s name;
      2. b. The patient’s address;
      3. c. The patient’s date of birth;
      4. d. The name and contact information of the patient’s representative, if applicable; and
      5. e. Any known allergy including medication allergies or sensitivities;

   2. 2. If necessary for treatment, medication information that includes:

      1. a. A medication ordered for the patient; and

      2. b. A medication administered to the patient including:

         1. i. The date and time of administration;
         2. ii. The name, strength, dosage, amount, and route of administration;
         3. iii. The identification and authentication of the individual administering the medication; and
         4. iv. Any adverse reaction the patient has to the medication;
   3. 3. Documentation of general and, if applicable, informed consent for treatment by the patient or the patient’s representative, except in an emergency;
   4. 4. An admitting diagnosis or reason for outpatient medical services;
   5. 5. Orders;
   6. 6. Documentation of hospital services provided to the patient; and

   7. 7. If applicable:

      1. a. A laboratory report,
      2. b. A pathology report,
      3. c. An autopsy report,
      4. d. A radiologic report,
      5. e. A diagnostic imaging report,
      6. f. Documentation of restraint or seclusion, and
      7. g. A consultation report.

5. E. In addition to the requirements in subsection (D), an administrator shall ensure that the hospital’s record of emergency services provided to a patient contains:

   1. 1. Documentation of treatment the patient received before arrival at the hospital, if available;
   2. 2. The patient’s medical history;
   3. 3. An assessment, including the name of the individual performing the assessment;
   4. 4. The patient’s chief complaint;
   5. 5. The name of the individual who treated the patient in the emergency room, if applicable; and
   6. 6. The disposition of the patient after discharge.

Historical Note

Former Section R9-10-213 renumbered as R9-10-313 as an emergency effective February 23, 1979, new Section R9-10-213 adopted effective February 23, 1979 (Supp. 79-1). Section repealed; new Section made by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). Amended by final rulemaking at 11 A.A.R. 536, effective March 5, 2005 (Supp. 05-1). Section R9-10-213 renumbered to R9-10-211; new Section R9-10-213 renumbered from R9-10-228 and 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).