Tenn. Comp. R. & Regs. 1180-01-.06 - Requirements for Creation and Maintenance of Patient Records for Licensed Psychologists, Senior Psychological Examiners and Psychological Examiners

Requirements for Creation and Maintenance of Patient Records for  Licensed Psychologists, Senior Psychological Examiners and Psychological Examiners

The provisions of this statute shall be in compliance with Tennessee Code Annotated §63-2-101 which governs the relase of medical records and Tennessee Code Annotated §63-3-102 which establishes the rules for copying and mailing records to patients who request a copy.

In order to maintain the minimum standard of care, a psychologist must create a record for every patient who receives services or consultation from the psychologist. If notice must be given to a patient, the psychologist must do so within thirty days and may do so by publication or posting. Patient records shall include medical history, summary of diagnoses, prognoses, records of treatment, medication given, and additional information that is necessary to insuring that a subsequent psychologist reviewing the files can determine the basis for the diagnosis, treatment plan and outcomes and can continue to provide care. Records should include mode and frequency of treatment, results of clinical tests, counseling session start and stop times, summaries of diagnosis and functional status, treatment plans, symptoms, prognosis, and progress. Raw test data and materials and psychotherapy notes shall not be included the records.

The process of notifying patients of a psychologist who leaves a group practice shall be governed by a contract. However, the patient must be notified within eighteen months of the psychologists departure unless there have been fewer than two office encounters between the psychologist and patient. The patient must be allowed to have records transferred to a new psychologist, and the practice may not withhold records if the patient decides to continue with the same psychologist who has relocated elsewhere. Choice of practitioner shall be left to the patient.

Patient records shall be retained for at least seven years from the last clinical contact between a patient and psychologist. Records of incompetent patients shall be retained indefinitely, and records of minors shall be retained for at lest one year after the minor turns eighteen or seven years from the date of the last clinical contact—whichever is longer. If there is a dispute over services, a patient’s record may not be destroyed until that dispute is resolved.

Tenn. Code Ann. § 63-2-101

Tenn. Code Ann. § 63-2-102