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Patient Medical Record

RDA Number
2305
Effective Date
Record Series Abstract
Records include but not limited to: preadmission and admission documents, clinical treatment records, discharge summaries, aftercare services, death certificates, quality management reports, and orders for judicial commitment.
Record Series Active
Yes
Cut Off at End of
Other
If Other, Explain
Patient Discharge/age of majority (18 years old).
Total Retention Years
10
Total Retention Months
0
Retention End Action
Destroy
Disposition Notes
Cut off at the end of each patient’s most recent discharge/age of majority (18 years old). Records that are maintained as paper, will be with the agency as needed until they are transferred to the State Records Center for the remaining retention time. Electronic records shall be maintained with the agency for full retention time. Paper and electric records shall be kept for a minimum of 10 years. After 10 years, the Agency shall review paper and electronic records and determine whether to retain the record for an additional specified period at the discretion of the Appointing Authority or their designee or destroy the record using state-approved methods. Electronic records shall be maintained using the Agency’s Electronic Medical Records System.
Record Location
Each Facility's Central/Medical Records Department; Order for Judicial Commitment will be held in LEGAL Counsel's Office AT 500 DEADERICK ST, ANDREW JACKSON BLDG., 5th floor, NASHVILLE, TN 37243.
File Arrangement
Numerical
Media Format Generated
Electronic
Paper
Media Format Generated Summary
Electronic: Text
Paper: Sheet
Media Format Stored
Electronic
Paper
Film
Media Format Stored Summary
Electronic: Text
Paper: Sheet
Film: Microfilm
Film: Microfiche
Date Range
1944 to Current
Allotment Code
339
Annual Accumulation
776 cu ft, 700 gigabytes, Microfiche Sheets 0, Microfilm rolls 0, CD ROM Disks 0
Current Volume
19,011 cu ft, 2.5 terabytes, Microfiche Sheets 133,400, Microfilm Rolls 791, CD ROM Disks 216
Record Value
Administrative
Legal
Audit Requirements
State
Information Shared Outside the State
No
Essential Record
Yes - Original
Essential Record Stored
MIDDLE TN MENTAL HEALTH INSTITUTE-DONELSON, WESTERN MENTAL HEALTH INSTITUTE-BOLIVAR, MOCCASIN BEND MENTAL HEALTH INSTITUTE-CHATTANOOGA, MEMPHIS MENTAL HEALTH INSTITUTE-MEMPHIS, VITAL RECORDS CONTROL (VRC)-NASHVILLE
Essential Record Media Type
Paper
Confidential
Yes
Confidential Legal Citation
Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its accompanying regulations codified at 45 C.F.R. Parts 160 through 164; and 42 U.S.C. 290dd-2 and its accompanying regulations codified at 42 C.F.R. Part 2. As well as TCA 33-3-103 for records confidentiality.
Does this Record Series Contain Sensitive Information?
Yes
Agency Retention
10 years
Records Center Retention Period
10 years
System Name
Windows File Servers
Hardware Description
THE ELECTRONIC RECORDS ARE STORED ON A STRATEGIC TECHNOLOGY SOLUTIONS(STS) SERVER OR ON THE VENDOR’S SERVERS. ALL HARDWARE FOR MAINTAINING THE RECORD SERIES SHALL BE MAINTAINED IN ACCORDANCE WITH THE CURRENT FEDERAL AND STATE LAWS, RULES, AND REGULATIONS.
Software Description
PAPER DOCUMENTS ARE CAPTURED BY USING SOFTWARE ON THE MULTI-FUNCTION DEVICES AND SCANNING THE PAPER DOCUMENT. ELECTRONIC DOCUMENTS ARE MAINTAINED USING THE AGENCY’S ELECTRONIC MEDICAL RECORDS SYSTEM.
System Location
THE ELECTRONIC RECORDS ARE KEPT ON A SERVER MAINTAINED AND SUPPORTED BY STS AT THEIR DATA CENTER, 901 REP. JOHN LEWIS WAY N., NASHVILLE, TN. 37243 AND ON ELECTRONIC MEDICAL RECORDS SYSTEM VENDOR SERVERS.
Backup Procedures
BACKUP PROCEDURES SHALL BE MAINTAINED IN ACCORDANCE WITH THE CURRENT STANDARDS OF STS, LOCATED IN THE 901 REP. JOHN LEWIS WAY N., STS BUILDING, NASHVILLE, TN. 37243. BACKUP PROCEDURES SHALL BE REVIEWED AND TESTED ANNUALLY.
Disaster Recovery
THE AGENCY SHALL HAVE A DETAILED DISASTER RECOVERY PLAN FOR THE SYSTEM IN ACCORDANCE WITH THE CURRENT STANDARDS OF STS. THE DISASTER RECOVERY PLANS SHALL BE REVIEWED ANNUALLY.
Data Migration Description
PAPER DOCUMENTS ARE SCANNED TO THE STATE NETWORK TO A FOLDER ON AN STS SERVER. THE VENDOR FOR THE ELECTONIC MEDICAL RECORDS SYSTEM WILL BE REQUIRED TO FACILITATE THE MIGRATION OF ELECTRONIC DOCUMENTS AS NEEDED.
Records Management Division (RMD)
03-16-2023
No recommended changes.
Tennessee State Library and Archives
03-21-2023
No recommended changes.
Comptroller Audit Review
03-21-2023
We have reviewed RDA 2305 from an audit standpoint. We concur with the recommended retention and disposition specifications.
Agency Records Officer
03-22-2023
Thank you.
RMD Director
03-24-2023
RDA 2305 is a request to revise an RDA. The retention period will remain ten years and then destroy. The format will be paper/electronic/film. The Abstract, Disposition Notes and Worksheet have been updated. Recommend approval of the request to revise RDA 2305.
Public Records Commission
04-18-2023
PRC approves RDA 2305.