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Tenn. Comp. R. & Regs. 1200-08-01-.11 - Hospital Records and Reporting Requirements

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All hospitals must report the following:

  •         All births, deaths, and reportable fetal deaths occurring within the hospital to the local county registrar, or as otherwise directed by the state registrar, on the third day of the month after the month in which the event occurred;
  •         A certificate of live birth for each live birth occurring within or en route to the hospital to the state registrar within ten days of the birth;
  •         Joint annual report data within 150 days of the end of the hospitals fiscal year or of the hospital’s closure or change of ownership;
  •         Each case of communicable disease to the local county health office;
  •         Abuse of a patient or an unexpected occurrence or accident that results in the death or serious injury of a patient to the department of health within seven business days of identification of such event;
  •         Specific incidents that might result in a disruption of services at the hospital to the department of health within seven days of identification of such incident;
  •         Information contained in the medical records of patients who have cancer or pre-cancerous or tumorous diseases to the cancer reporting system within six months of diagnosis or treatment;
  •         Claims data for all discharges, at least quarterly;
  •         Traumatic brain injuries to the department of health, including the name, age and residence of the injured person and, as requested, information collected by computer in the hospital’s medical records department.

Grounds for disciplinary action include:

  •         Failure to report an adverse event;
  •         Failure to submit an acceptable plan of correction to the department of health as required;
  •         Failure to comply with a plan of correction; and
  •         Repeated failure to report communicable diseases will be cause for a revocation of a hospital license.

Event reports must remain confidential and are not considered a public record.  Information contained in such reports may not be disclosed except:

  •       In a disciplinary proceeding conducted by the department of health;
  •       In a disciplinary proceeding conducted by the appropriate regulatory board;
  •       If transmitted by the department of health to an appropriate regulatory board;
  •       If shared by the department of health with an appropriate governmental agency responsible for regulatory oversight of the hospital;
  •       If requested, the department of health must reveal its awareness that a specified incident has been reported; and
  •       As appropriate, notification of the affected patient and the patient’s family by the hospital.

The department may copy any portion of a hospital medical record relating to the reported event unless otherwise prohibited.

Current as of June 2015