Tenn. Comp. R. & Regs. 1155-02-.18 - MEDICAL RECORDS

Current through March 20, 2022

(1) Purpose
(a) To recognize that medical records are an integral part of the practice of podiatrists as defined in T.C.A. § 63-3-101.
(b) To give podiatrists, their professional and non-professional staff, and the public direction about the content, transfer, retention, and destruction of those records.
(2) Applicability. This rule regarding medical records shall apply only to those records, the information for which was obtained by podiatrists or their supervisees, for purposes of services provided in any clinical setting other than a hospital as defined by T.C.A. § 68-11-302(4), a hospital emergency room, or hospital outpatient facility.
(3) Medical Records
(a) Duty to Create and Maintain Medical Records - As a component of the standard of care and of minimal competency, a podiatrist must cause to be created and cause to be maintained a medical record for every encounter between a patient and either the podiatrist or licensed member of the podiatrist's staff. All imaging studies and interpretations of such studies are considered to be part of the patient's medical records. For purposes of this Rule, a patient is defined as a person for whom the podiatrist has undertaken to diagnose or treat or for whom the podiatrist has participated in such diagnosis or treatment.
(b) Notice - Any notice required by these rules to be provided to a patient shall be issued within thirty (30) days of the date of the event that triggers the notice requirement, and shall be accomplished by mailing to the last known address of the patient.
(c) Content - In order to meet the minimum level of competency required of podiatrists, the medical records required by this rule shall:
1. Be recorded in such a manner as to be legible to an ordinary reasonable person, including those persons who are not licensed healthcare professionals;
2. Include all information and documentation listed in T.C.A. § 63-2-101(c)(4);
3. Contain such additional information that is necessary to insure that a subsequent reviewing or treating physician can both ascertain the basis for the diagnosis, treatment plan, and outcomes, and provide continuity of care for the patient.
(d) Transfer
1. Inapplicability of Notice Requirements - None of the notice requirements of this subparagraph (d) are required for patients who have had fewer than three (3) office encounters with the podiatrist or his licensed supervisees over the eighteen (18) month period that immediately precedes the event that would otherwise trigger the notice.
2. Records of Podiatrists upon Death or Retirement - When a podiatrist retires or dies while in practice, patients seen by the podiatrist in his office during the immediately preceding eighteen (18) months shall be notified by the podiatrist, or his authorized representative, urged to find a new podiatrist, and informed that upon authorization copies of the patient's medical records will be sent to the new podiatrist or other physician.
3. Records of Podiatrists upon Departure from a Group - The responsibility for notifying patients of a podiatrist who leaves a group practice for any reason other than death shall be governed by the podiatrist's employment contract. If the employment contract does not address the notification issue, the group shall be responsible for notifying the podiatrist's patients that the podiatrist has departed from the group.
(i) Whoever is responsible for the notification must notify patients seen by the podiatrist in his office during the eighteen (18) months immediately preceding his departure.
(ii) Those patients shall also be notified of the podiatrist's new address and offered the opportunity to have copies of their medical records forwarded to the departing podiatrist at his new practice. A group shall not withhold the medical records of any patient who has authorized their transfer to the departing podiatrist or any other podiatrist or other physician.
(iii) The choice of podiatrist in every case should be left to the patient, and the patient should be informed that upon authorization his records will be sent to the podiatrist or other physician of the patient's choice.
4. Sale of a Podiatry Practice - A podiatrist or the estate of a deceased podiatrist may sell the elements that comprise his practice, which include the goodwill of the practice and the opportunity to take over the patients of the seller by purchasing the medical records. Therefore, the transfer of medical records of patients upon the sale of a podiatry practice is subject to the following:
(i) The podiatrist (or the estate) must ensure that all medical records are transferred to another podiatrist, other physician, or entity that is held to the same standards of confidentiality as provided in these rules.
(ii) Patients seen by the podiatrist in his office during the immediately preceding eighteen (18) months shall be notified that the podiatrist (or the estate) is transferring the practice to another podiatrist, other physician, or entity who will retain custody of their medical records and that at their written request copies of their records will be sent to another podiatrist, other physician, or entity of their choice.
5. Failure to Adequately Provide for Transfer of Records or Notice to Patients. It shall be a prima facie violation of T.C.A. § 63-3-119(a)(4) and (10) for a podiatrist to depart from his group, retire, or sell his practice without making provision for the security or transfer of patient medical records, or otherwise establish a secure method of patient access to his medical records.
(e) Retention of Medical Records - Medical records shall be retained for a period of not less than seven (7) years from the podiatrist's or his supervisees' last professional contact with the patient except for the following:
1. Medical records for incompetent patients, other than those who are incompetent solely because they are minors, shall be retained until at least one (1) year after the patient's death.
2. Medical records of minors shall be retained for a period of not less than one (1) year after the minor reaches the age of majority or ten (10) years from the date of the podiatrist's or his supervisees' last professional contact with the patient, whichever is longer.
3. Notwithstanding the foregoing, no medical record involving services which are currently under dispute shall be destroyed until the dispute is resolved.
(f) Destruction of Medical Records
1. No medical record shall be singled out for destruction other than in accordance with established office operating procedures.
2. Medical records shall be destroyed only in the ordinary course of business according to established office operating procedures that are consistent with these rules.
3. Physical copies of medical records may be destroyed by burning, shredding, or other method that safeguards patient protected health information from any use or disclosure that is in violation of any state or federal laws or regulations.
4. Any recordable and erasable media device upon which electronic medical records have been stored must be rendered inaccessible, cleaned, or scrubbed by overwriting the data, degaussing the media (using magnetic field to neutralize the data stored on magnetic media), or other method that safeguards patient protected health information. Simply discarding a data storage device without rendering the data stored upon it inaccessible, cleaned, or scrubbed does not constitute compliance with this rule.
5. When medical records are destroyed, the time, date and circumstances of the destruction shall be recorded and maintained for future reference. The record of destruction need not list the individual patient medical records that were destroyed but shall be sufficient to identify which group of destroyed records contained a particular patient's medical records.
(4) In addition to the requirements of this rule, podiatrists must also comply with the Health Insurance Portability and Accountability Act (HIPAA) and the regulations promulgated thereto. Failure to comply with HIPAA shall constitute violation of this rule.
(5) Mandatory Release of Patient Records
(a) Upon request from a patient or the patient's authorized representative, an individual registered with this Board shall provide a complete copy of the patient's records or a summary of such records which were maintained by the provider.
(b) It shall be the provider's option as to whether copies of the records or a summary will be given to the patient.
(c) Requests for records shall be honored by the provider in a timely manner.
(6) Violations - Violation of any provision of these rules is grounds for disciplinary action pursuant to T.C.A. §§ 63-3-119(a)(4), 63-3-119(a)(8), and 63-3-119(a)(10).
(7) This rule shall be applied prospectively. A podiatrist shall not be found to be in violation of this rule if the violation occurred before the effective date of this rule.

Notes

Tenn. Comp. R. & Regs. 1155-02-.18
Original rule filed November 10, 1998; effective January 14, 1999. Amendments filed May 7, 2019; effective 8/5/2019.

Authority: T.C.A. §§ 4-5-202, 4-5-204, 63-2-101, and 63-2-102.

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