1. A. An administrator shall ensure that:

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

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

      1. a. Authorized according to policies and procedures to access the resident’s medical record;
      2. b. If the individual is not authorized according to policies and procedures, with the written consent of the resident or the resident’s representative; or
      3. c. As permitted by law;
   6. 6. Policies and procedures include the maximum time-frame to retrieve a resident’s medical record at the request of a medical practitioner, behavioral health professional, or authorized personnel member; and
   7. 7. A resident’s medical record is protected from loss, damage, or unauthorized use.

2. B. If a behavioral health residential facility maintains residents’ 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 resident’s medical record is recorded by the computer’s internal clock.

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

   1. 1. Resident information that includes:

      1. a. The resident’s name;
      2. b. The resident’s address;
      3. c. The resident’s date of birth; and
      4. d. Any known allergies, including medication allergies;
   2. 2. The name of the admitting medical practitioner or behavioral health professional;
   3. 3. An admitting diagnosis or presenting behavioral health issues;
   4. 4. The date of admission and, if applicable, date of discharge;

   5. 5. If applicable, the name and contact information of the resident’s representative and:

      1. a. If the resident is 18 years of age or older or an emancipated minor, the document signed by the resident consenting for the resident’s representative to act on the resident’s behalf; or

      2. b. If the resident’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;
   6. 6. If applicable, documented general consent and informed consent for treatment by the resident or the resident’s representative;
   7. 7. Documentation of medical history and results of a physical examination;
   8. 8. A copy of resident’s health care directive, if applicable;
   9. 9. Orders;
   10. 10. If applicable, documentation that evaluation or treatment was ordered by a court according to A.R.S. Title 36, Chapter 5 or A.R.S. § 8-341.01;
   11. 11. Assessment;
   12. 12. Treatment plans;
   13. 13. Interval notes;
   14. 14. Progress notes;
   15. 15. Documentation of behavioral health services and physical health services provided to the resident;
   16. 16. If applicable, documentation of the use of an emergency safety response;
   17. 17. If applicable, documentation of time-out required in R9-10-714(6);
   18. 18. Except as allowed in R9-10-707(E)(1)(d), documentation of freedom from infectious tuberculosis required in R9-10-707(A)(13);
   19. 19. The disposition of the resident after discharge;
   20. 20. The discharge plan;
   21. 21. The discharge summary, if applicable;

   22. 22. If applicable:

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

   23. 23. Documentation of medication administered to the resident 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, when administered initially or on a PRN basis:

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

       4. d. For a psychotropic medication, when administered initially or on a PRN basis:

          1. i. An assessment of the resident’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 providing assistance in the self-administration of the medication; and
       6. f. Any adverse reaction a resident has to the medication.

Historical Note

Adopted 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). Section repealed; 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 rulemaking at 25 A.A.R. 1583, effective October 1, 2019 (Supp. 19-3). Amended by final expedited rulemaking at 26 A.A.R. 551, with an immediate effective date of March 3, 2020 (Supp. 20-1).