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TENN. COMP. R. & REGS. 1200-08-01-.06(5) - Hospital functions under the Department of Health, Department of Environment and Conservation, and Department of Finance and Administration regulations

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Hospitals must maintain patient records and retain them for 10 years or, in the case of a minor, 1 year past the minor’s 18th birthday.
A hospital must timely transfer copies when requested by other practitioners or facilities. The hospital’s medical record service must be supervised by a Registered Health Information Administrator, a Registered Health Information Technician, or a person with appropriate work experience. The medical record service must be adequately staffed to ensure timely completion, filing and retrieval of records.
Records must be accurate, completed in a timely manner, filed properly, and accessible. The hospital must store records in a manner that ensures security and integrity of authentication.
Records may be destroyed by burning, shredding, or other similar method that ensures confidentiality. Destruction of records must be documented, and no record may be destroyed on an individual basis.
Records must be coded and indexed according to diagnosis and procedure, in a manner that allows timely retrieval. A hospital must have policies and procedures in place to ensure confidentiality. Specifically, information may only be released to authorized individuals. Original records can only be released as authorized be law, court order, or subpoena.
The record must contain information sufficient to justify admission, diagnosis, progress, and response to medication. Entries must be legible, complete, dated and authenticated. Specifically, each record must include the following:
·         Health history and physical examination
·         Diagnoses
·         Results of evaluations
·         Documentation of complications
·         Signed consent forms
·         Orders, notes, reports, and vital signs
·         Discharge summary

Current as of January 2016