Tenn. Comp. R. & Regs. 1045-02-.14 - 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.
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.
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).
Notes
Authority: T.C.A. § 4-5-202, 4-5-204, 63-2-101, 63-2-102, 63-8-112, and 63-8-120.
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