Patient Records

(1) Purposes - The purposes of these rules are: (a) To recognize that patient records are an integral part of the practice of psychologists, senior psychological examiners, and psychological examiners as defined in T.C.A. §§ 63-11-202 and 63-11-203. GENERAL RULES GOVERNING THE PRACTICE OF PSYCHOLOGISTS, CHAPTER 1180-01 SENIOR PSYCHOLOGICAL EXAMINERS, PSYCHOLOGICAL EXAMINERS, CERTIFIED PSYCHOLOGICAL ASSISTANTS, AND CERTIFIED PSYCHOLOGICAL TESTING TECHNICIANS (b) To give psychologists, senior psychological examiners and psychological examiners, their professional and non-professional staff, and the public direction about the content, transfer, retention, and destruction of those records. (2) Conflicts - As to patient records, these rules should be read in conjunction with the provisions of T.C.A. §§ 63-2-101 and 63-2-102, 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 patient records shall apply only to those records, the information for which was obtained by psychologists, senior psychological examiners and psychological examiners or their professionally certified 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) Patient Records - (a) Duty to Create and Maintain Patient Records - As a component of the standard of care and of minimal competency a psychologist, senior psychological examiner or psychological examiner must cause to be created and cause to be maintained a record for every patient for whom he or she, and/or any of his or her professionally certified supervisees, performs services or provides professional consultation. (b) Notice - Anywhere in these rules where notice is required to be given to patients of any psychologist, senior psychological examiner or psychological examiner, 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 including, but not limited to: 1. Publication of the required information in a newspaper of general circulation in the area in which the licensee practices; or 2. Posting of the required information at the practice location. (c) Content - All patient records, or summaries thereof, produced in the course of the practice of psychology 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 psychologist, senior psychological examiner or psychological examiner can both ascertain the basis for the diagnosis, treatment plan and outcomes, and provide continuity of care for the patient. 1. Patient records include, but are not limited to: (i) The name of the patient and other identifying information; (ii) The presenting problem(s) or purpose of diagnosis; (iii) The fee arrangement; (iv) The date and substance of each billed or service-count contact or service; GENERAL RULES GOVERNING THE PRACTICE OF PSYCHOLOGISTS, CHAPTER 1180-01 SENIOR PSYCHOLOGICAL EXAMINERS, PSYCHOLOGICAL EXAMINERS, CERTIFIED PSYCHOLOGICAL ASSISTANTS, AND CERTIFIED PSYCHOLOGICAL TESTING TECHNICIANS (v) Any test results or other evaluative results obtained and any basic test data from which they were derived (not including protocols); (vi) Notation and results of formal consults with other providers; (vii) A copy of all test and other evaluative reports prepared as a component of the professional relationship; and (viii) Any releases executed by the patient. 2. Not included in patient records are test materials, such as manuals, instruments, protocols, and test questions or stimuli. Although not included in patient records, test materials such as manuals, instruments, protocols, and test questions or stimuli must be retained in accordance with the “Ethical Principles of Psychologists and Code of Conduct” published by the American Psychological Association. (d) Transfer - 1. Records of Psychologists, Senior Psychological Examiners and Psychological Examiners Upon Death or Retirement - When a psychologist, senior psychological examiner or psychological examiner retires or dies while in practice, patients seen by the psychologist, senior psychological examiner or psychological examiner in his/her office during the immediately preceding eighteen (18) months shall be notified, as provided in subparagraph (b), by the psychologist, senior psychological examiner, psychological examiner or his/her authorized representative and be informed that upon authorization, copies of the records will be sent to the new psychologist, senior psychological examiner or psychological examiner. 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 Psychologists, Senior Psychological Examiners and Psychological Examiners upon Departure from a Group - The responsibility for notifying patients of a psychologist, senior psychological examiner or psychological examiner who leaves a group practice whether by death, retirement or departure shall be governed by the employment contract of the psychologist, senior psychological examiner or psychological examiner. (i) Whomever is responsible for that notification must notify patients seen by the psychologist, senior psychological examiner or psychological examiner in his/her office during the immediately preceding eighteen (18) 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 employment contract, those patients shall also be notified of the practitioner’s new address and offered the opportunity to have copies of their records forwarded to the departing psychologist, senior psychological examiner or psychological examiner at his or her new practice. Provided however, a group shall not withhold the records of any patient who has authorized their GENERAL RULES GOVERNING THE PRACTICE OF PSYCHOLOGISTS, CHAPTER 1180-01 SENIOR PSYCHOLOGICAL EXAMINERS, PSYCHOLOGICAL EXAMINERS, CERTIFIED PSYCHOLOGICAL ASSISTANTS, AND CERTIFIED PSYCHOLOGICAL TESTING TECHNICIANS transfer to the departing psychologist, senior psychological examiner or psychological examiner or any other practitioner. (iii) The choice of practitioner 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 psychologist, senior psychological examiner or psychological examiner of the patient’s choice. 3. Sale of a Psychology Practice - A psychologist, senior psychological examiner or psychological examiner or the estate of a deceased psychologist, senior psychological examiner or psychological examiner 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 patient records. Therefore, the transfer of records of patients is subject to the following: (i) The psychologist, senior psychological examiner or psychological examiner (or the estate) must ensure that all patient records are transferred to another psychologist, senior psychological examiner or psychological examiner or entity that is held to the same standards of confidentiality as provided in these rules. (ii) Patients seen by the psychologist, senior psychological examiner or psychological examiner in his/her office during the immediately preceding eighteen (18) months shall be notified that the psychologist, senior psychological examiner or psychological examiner (or the estate) is transferring the practice to another practitioner 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 practitioner 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 psychologist, senior psychological examiner or psychological examiner shall not be considered as abandonment. (i) It shall be a prima facie violation of T.C.A. § 63-11-215(b)(1) for a psychologist, senior psychological examiner or psychological examiner 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 psychologist, senior psychological examiner or psychological examiner 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 records by whatever lawful means available and should immediately seek the services of another psychologist, senior psychological examiner or psychological examiner. (e) Retention of Patient Records - Patient records shall be retained for a period of not less than seven (7) years from the last clinical contact between the patient and the psychologist, senior psychological examiner or psychological examiner, or their professionally certified supervisees except for the following: GENERAL RULES GOVERNING THE PRACTICE OF PSYCHOLOGISTS, CHAPTER 1180-01 SENIOR PSYCHOLOGICAL EXAMINERS, PSYCHOLOGICAL EXAMINERS, CERTIFIED PSYCHOLOGICAL ASSISTANTS, AND CERTIFIED PSYCHOLOGICAL TESTING TECHNICIANS 1. Records for incompetent patients shall be retained indefinitely. 2. 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 seven (7) years from the date of the last clinical contact with the patient, whichever is longer. 3. Notwithstanding the foregoing, no patient record involving services which are currently under dispute shall be destroyed until the dispute is resolved. (f) Destruction of Patient Records - 1. No patient 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. (5) Violations - Violation of any provision of these rules is grounds for disciplinary action pursuant to T.C.A. §§ 63-11-215(b)(1), and/or (2).