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Peer Review Reports and Administrative Reports

Core Data
RDA Number
11285
Effective Date
Record Series Abstract
Records include but are not limited to: The Joint Commission Review as needed and or requested, quarterly peer review reports. Including form titles: Ongoing professional Practice Evaluation (OPPE).
Record Series Active
Yes
Cut Off at End of
Other
If Other, Explain
Expiration of Joint Commission Review period
Total Retention Years
6
Total Retention Months
0
Retention End Action
Destroy
Disposition Notes
Maintain for six years after the expiration of each Joint Commission Review period and then destroy. Records are generated and maintained on both paper and electronic. Paper records may be destroyed once scanned and verified for completeness and accuracy.
Worksheet
Record Location
At each of the Regional Mental Health Institutes: Middle MHI - 221 Stewarts Ferry Pk, Nashville, TN 37214. Western MHI - 11100 Hwy 64, Bolivar, TN 38008. Moccasin Bend MHI - 100 Moccasin Bend Rd, Chattanooga, TN 37405. Memphis MHI - 951 Court Ave, Memphis, TN 38103.
File Arrangement
Date
Media Format Generated
Both
Date Range
2012 - current
Agency
Dept. of Mental Health
Allotment Code
339
Annual Accumulation
12 cu. ft. 1 gigabyte
Current Volume
15 cu. ft. 1 gigabyte
Record Value
Administrative
Audit Requirements
State
Information Shared Outside the State
No
Essential Record
Yes - Original
Essential Record Stored
Regional Mental Health Institutes @ Nashville, Chattanooga, Bolivar and Memphis.
Essential Record Media Type
Paper
Confidential
No
Does this Record Series Contain Sensitive Information?
No
Agency Retention
6 years
Records Center Retention Period
0
Electronic Records Plan Inventory
System Name
Oracle file servers
Hardware Description
The electronic records are stored in folders on a strategic technology solutions (STS) server. All hardware for maintaining the record series shall be maintained in accordance with the current standards of STS.
Software Description
Documents and metadata are captured by using multi-function devices and scanning the document by pressing the appropriate button on the multi-function device using Lexmark document distributor software.
System Location
The electronic records are kept on a server maintained and supported by STS at their Data Center, 901 5th Ave N, Nashville, TN. 37243.
Backup Procedures
Backup procedures shall be maintained in accordance with the current standards of STS, located in the 901 5th Ave 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
Documents are scanned to the state network to a folder on a STS server. The metadata captured at the time of scan is stored in a Microsoft SQL server database and is deleted at the 6 year retention disposition.
Metadata Description
Metadata varies based on the document type. Below is a list of some data elements; patient's first name, middle initial, last name, social security number, address, tracking number, document group, document type, county, district, filename, total pages, file size, audit elements such as tracking number, varied by, date created, active, closed, pending, deleted, etc. The data sets are, but not limited to, excel, word, text, pdf, pictures, image files (tiff etc.) and email exports. Any electronic file that is relevant to patient medical record files will be in the folder structure.
RDA Comments
Records Management Division (RMD)
03-29-2018
Recommend cut off not be calendar year but more specific to the record series. Missing Audit Requirements. Please explain reasoning for 6 year retention. Please confirm if these records are confidential.
Tennessee State Library and Archives
03-29-2018
TSLA concurs in RMD comments.
Comptroller Audit Review
03-29-2018
Audit concurs with RMD comments.
Agency Records Officer
04-02-2018
We concur. The files are to be cut off at the end of each calendar year. Are records subject to fiscal audit? No. The records are to be maintained in agency 6 tears, because that's when the Joint Commission's review period expires. These records are not confidential.
RMD Director
04-03-2018
RDA 11285 is a request to create an RDA. The retention period will be six years and destroy. The format will be paper/electronic. Recommend approval of the request to create RDA 11285 with the following changes: Cut Off: Other If Other, Explain: Expiration of Joint Commission Review period Total Retention: 6 Years Disposition Notes: Maintain for six years after the expiration of each Joint Commission Review period and then destroy. Records are generated and maintained on both paper and electronic. Paper records may be destroyed once scanned and verified for completeness and accuracy. Audit Requirements: State (Agency agreed to Director Recommendations on 4/6/2018)
Public Records Commission
04-25-2018
PRC approves RDA 11285 with following changes: Cut Off: Other If Other, Explain: Expiration of Joint Commission Review period Total Retention: 6 Years Disposition Notes: Maintain for six years after the expiration of each Joint Commission Review period and then destroy. Records are generated and maintained on both paper and electronic. Paper records may be destroyed once scanned and verified for completeness and accuracy. Audit Requirements: State (Agency agreed to Director Recommendations on 4/6/2018)