Medical Records

(1) Purposes - The purposes of these rules are: (a) To recognize that medical records are an integral part of the practice of osteopathic medicine as defined in T.C.A. § 63-9-106. (b) To give physicians, their professional and non-professional staff, and the public direction about the content, transfer, retention, and destruction of those records. (c) To recognize that a distinction exists between a physician’s medical records for a patient receiving services in the physician’s office and those records created by the physician for that patient for purposes of services provided in a hospital as defined by T.C.A. § 68-11-302(4) and that the distinction exists regardless of the fact that the physician may also be an employee of the hospital or of a medical group employed or owned by the hospital. (2) Conflicts - As to medical records, these rules should be read in conjunction with the provisions of T.C.A. §§ 63-2-101 and 102, and are not intended to conflict with those statutes in any way. Those statutes, 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 medical records shall apply only to those records, the information for which was obtained by physicians or their professionally licensed 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) Medical Records - GENERAL RULES AND REGULATIONS GOVERNING CHAPTER 1050-02 THE PRACTICE OF OSTEOPATHY (a) Duty to Create and Maintain Medical Records - As a component of the standard of care and of minimal competency a physician must cause to be created and cause to be maintained a medical record for every patient for whom he or she, and/or any of his or her professionally licensed supervisees, performs services or provides professional consultation. (b) Notice - Anywhere in these rules where notice is required to be given to patients of any physician 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. (c) Distinguished from Hospital Medical Records - The medical records covered by these rules are separate and distinct from those records generated for the patient by the physician during the course of providing medical services for the patient in a hospital as defined by T.C.A. § 68-11-302(4) regardless of the fact that the physician may also be an employee of the hospital or of a medical group employed or owned by the hospital. 1. The provisions of T.C.A. Title 68, Part 11, Chapter 3 govern medical records generated in a hospital as defined by T.C.A. § 68-11-302(4). 2. The medical records covered by these rules are those: (i) That are created prior to the time of the patient’s admission to or confinement and/or receipt of services in a hospital as defined by T.C.A. § 68-11-302(4), hospital emergency room and/or hospital outpatient facility, and/or (ii) That are created after the patient’s discharge from a hospital as defined by T.C.A. § 68-11-302(4), hospital emergency room or hospital outpatient facility. (iii) That are created during the practice of medicine as defined by T.C.A. § 63- 6-204 outside of a hospital as defined by T.C.A. § 68-11-302(4), hospital emergency room or hospital outpatient facility. 3. Even though the records covered by these rules may, of necessity, reference provision of services in the hospital setting and the necessary initial work-up and/or follow-up to those services, that does not make them “hospital records” that are regulated by or obtainable pursuant to T.C.A. Title 68, Part 11, Chapter 3. (d) Content - All medical records, or summaries thereof, produced in the course of the practice of medicine for all patients shall include all information and documentation listed in T.C.A. § 63-2-101(c)(4) and 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. (e) Transfer - 1. Records of Physicians upon Death or Retirement - When a physician retires or dies while in practice, patients seen by the physician in his/her office during the immediately preceding thirty-six (36) months shall be notified by the physician, or his/her authorized representative and urged to find a new physician and be informed that upon authorization, copies of the records will be sent to the new GENERAL RULES AND REGULATIONS GOVERNING CHAPTER 1050-02 THE PRACTICE OF OSTEOPATHY physician. This notification requirement shall not apply to a patient when there have been fewer than two (2) office patient encounters within the immediately preceding eighteen (18) months. 2. Records of Physicians upon Departure from a Group - The responsibility for notifying patients of a physician who leaves a group practice whether by death, retirement or departure shall be governed by the physician’s employment contract. (i) Whomever is responsible for that notification must notify patients seen by the physician in his/her office during the immediately preceding thirty-six (36) months of his/her departure, except that this notification requirement shall not apply to a patient when there have been fewer than two (2) office patient encounters within the immediately preceding eighteen (18) months. (ii) Except where otherwise governed by provisions of the physician’s contract, those patients shall also be notified of the physician’s new address and offered the opportunity to have copies of their medical records forwarded to the departing physician at his or her new practice. Provided however, a group shall not withhold the medical records of any patient who has authorized their transfer to the departing physician or any other physician. (iii) The choice of physicians 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 physician of the patient’s choice. 3. Sale of a Medical Practice - A physician or the estate of a deceased physician 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 physician’s medical records. Therefore, the transfer of records of patients is subject to the following: (i) The physician (or the estate) must ensure that all medical records are transferred to another physician or entity that is held to the same standards of confidentiality as provided in these rules. (ii) Patients seen by the physician in his/her office during the immediately preceding thirty-six (36) months shall be notified that the physician (or the estate) is transferring the practice to another physician 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 physician or entity of their choice. This notification requirement shall not apply to a patient when there have been fewer than two (2) office patient encounters within the immediately preceding eighteen (18) months. 4. Abandonment of Records - For purposes of this section of the rules death of a physician shall not be considered as abandonment. (i) It shall be a prima facie violation of T.C.A. § 63-9-111(b)(1) for a physician to abandon his practice without making provision for the security, or transfer, or otherwise establish a secure method of patient access to their records. (ii) Upon notification that a physician in a practice has abandoned his practice and not made provision for the security, or transfer, or otherwise GENERAL RULES AND REGULATIONS GOVERNING CHAPTER 1050-02 THE PRACTICE OF OSTEOPATHY established a secure method of patient access to their records patients should take all reasonable steps to obtain their medical records by whatever lawful means available and should immediately seek the services of another physician. (f) Retention of Medical Records - Medical records shall be retained for a period of not less than ten (10) years from the physician’s or his supervisees’ last professional contact with the patient except for the following: 1. Immunization records shall be retained indefinitely. 2. Medical records for incompetent patients shall be retained indefinitely. 3. X-rays, radiographs and other imaging products shall be retained for at least four (4) years after which if there exist separate interpretive records thereof they may be destroyed. However, mammography imaging and reports shall be maintained for ten (10) years. 4. 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 physician’s or his supervisees’ last professional contact with the patient, whichever is longer. 5. Notwithstanding the foregoing, no medical record involving services which are currently under dispute shall be destroyed until the dispute is resolved. (g) Destruction of Medical Records - 1. No medical record shall be singled out for destruction other than in accordance with established office operating 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 medical records that were destroyed but shall be sufficient to identify which group of destroyed records contained a particular patient’s medical records. (5) Violations - Violation of any provision of these rules is grounds for disciplinary action pursuant to T.C.A. §§ 63-9-111(b)(1), and/or (2).