Optometric Records

(1) Purposes – The purposes of these rules are: (a) To recognize that optometric records are an integral part of the practice of optometry as defined in T.C.A. § 63-8-102. (b) To give optometrists, their professional and non-professional staff, and the public direction about the content, transfer, retention, and destruction of those records. (2) Conflicts – As to optometric records, these rules should be read in conjunction with the provisions of T.C.A. § 63-2-101, T.C.A. § 63-2-102 and Rule 1045-02-.11(1)(d), and are not intended to conflict with those statutes or rules in any way. Those statutes and rules, along with these rules, govern the subjects that they cover in the absence of other controlling state or federal statutes or rules to the contrary. (3) Applicability – These rules regarding optometric records shall apply only to those records, the information for which was obtained by optometrists or their employees, or those over whom they exercise supervision, for purposes of services provided in any clinical setting other than those provided in a hospital as defined by T.C.A. § 68-11-302(4), a hospital emergency room or hospital outpatient facility. (4) Optometric Records (a) Duty to Create and Maintain Optometric Records – As a component of the standard of care and of minimal competency an optometrist must cause to be created and maintained an optometric record for every patient for whom he or she, and/or any of his or her supervisees, performs services or provides professional consultation. (b) Notice – Anywhere in these rules where notice is required to be given to patients of any optometrist that notice shall be required to be issued within thirty (30) days of the date of the event that triggers the notice requirement, and may be accomplished by public notice or by any other means reasonably designed to inform the patients. (c) Content – All optometric records, or summaries thereof, produced in the course of the practice of optometry for all patients shall include all information and documentation listed in T.C.A. § 63-2-101(c)(2) and such additional information that is necessary to insure that a subsequent reviewing or treating optometrist can both ascertain the basis for the diagnosis, treatment plan and outcomes, and provide continuity of care for the patient. (d) Transfer 1. Records of Optometrists upon Death or Retirement – When an optometrist retires or dies while in practice, patients seen by the optometrist in his/her office during the immediately preceding thirty-six (36) months shall be notified by the optometrist, or his/her authorized representative and urged to find a new optometrist and be informed that upon authorization, copies of the records will be sent to the new optometrist. GENERAL RULES GOVERNING THE PRACTICE OF OPTOMETRY CHAPTER 1045-02 2. Records of Optometrists upon Departure from a Group – The responsibility for notifying patients of an optometrist who leaves a group practice whether by death, retirement, or departure shall be governed by the optometrist’s employment contract. (i) Whomever is responsible for that notification must notify patients seen by the optometrist in his/her office during the immediately preceding thirty-six (36) months of his/her departure. (ii) Except where otherwise governed by provisions of the optometrist’s contract, those patients shall also be notified of the optometrist’s new address and offered the opportunity to have copies of their medical records forwarded to the departing optometrist at his or her new practice. Provided however, a group shall not withhold the records of any patient who has authorized their transfer to the departing optometrist or any other optometrist. (iii) The choice of optometrist in every case should be left to the patient, and the patient should be informed that upon authorization his/her records will be sent to the optometrist of the patient’s choice. 3. Sale of an Optometric Practice – An optometrist or the estate of a deceased optometrist may sell the elements that comprise his/her practice, one of which is its goodwill, i.e., the opportunity to take over the patients of the seller by purchasing the optometrist’s records. Therefore, the transfer of records of patients is subject to the following: (i) The optometrist (or the estate) must ensure that all optometric records are transferred to another optometrist or entity that is held to the same standards of confidentiality as provided in these rules. (ii) Patients seen by the optometrist in his/her office during the immediately preceding thirty-six (36) months shall be notified that the optometrist (or the estate) is transferring the practice to another optometrist or entity who will retain custody of their records and that at their written request the copies of their records will be sent to another optometrist or entity of their choice. (e) Abandonment of Optometric Records – For purposes of this section of the rules death of an optometrist shall not be considered as abandonment. 1. It shall be a prima facie violation of T.C.A. § 63-8-120(a)2. for an optometrist to abandon his practice without making provision for the security, or transfer, or otherwise establish a secure method of patient access to their records. 2. Upon notification that an optometrist in a practice has abandoned his practice and not made provision for the security, or transfer, or otherwise established a secure method of patient access to their records, patients should take all reasonable steps to obtain their optometric records by whatever lawful means available and should immediately seek the services of another optometrist. (f) Retention of Optometric Records – Optometric records shall be retained for a period of not less than ten (10) years from the optometrist’s or his supervisees’ last professional contact with the patient except for the following: 1. Optometric records for incompetent patients shall be retained indefinitely. GENERAL RULES GOVERNING THE PRACTICE OF OPTOMETRY CHAPTER 1045-02 2. Optometric 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 optometrist’s or his supervisees’ last professional contact with the patient, whichever is longer. 3. Notwithstanding the foregoing, no optometric record involving services which are currently under dispute shall be destroyed until the dispute is resolved. (g) Destruction of Optometric Records 1. No record shall be singled out for destruction other than in accordance with established office procedures. 2. Records shall be destroyed only in the ordinary course of business according to established office operating procedures that are consistent with these rules. 3. Records may be destroyed by burning, shredding, or other effective methods in keeping with the confidential nature of the records. 4. When 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 optometric records that were destroyed but shall be sufficient to identify which group of destroyed records contained a particular patient’s optometric records. (5) Violations – Violation of any provision of these rules is grounds for disciplinary action pursuant to T.C.A. § 63-8-120(a)(2).