Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 883843 (X3) Date Survey Completed 05/13/2026
Name of Provider or Supplier Dickson Medical Associates Mathis Pediatrics Street Address, City, State 110 Mathis Drive, Suite 103, Dickson, TN
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
J0153 PATIENT HEALTH RECORDS

491.10(b) Protection of record information. (1) The clinic . . . maintains the confidentiality of record information and provides safeguards against loss, destruction or unauthorized use. (2) Written policies and procedures govern the use and removal of records from the clinic or center and the conditions for release of information. (3) The patient's written consent is required for release of information not authorized to be released without such consent.


This STANDARD is not met as evidenced by:
Based on policy review, observation, and interview, the clinic failed to ensure staff maintained the electronic medical record in a confidential manner for 1 of 6 patients observed. The findings included: Review of the facility policy titled "Medical Record Maintenance and Documentation," dated 04/01/2020, revealed "...the electronic medical record and the information contained within are to be held in strict confidence ..." Observations at the Nurse Station on 05/13/2026 at 9:10 AM, revealed Advanced Practical Registered Nurse (APRN) #1 left Patient #2's room with her laptop. APRN #1 placed her laptop on the Nursing Station counter and returned to Patient #2's room. APRN #1 left the laptop on the Nursing Station counter unlocked, displaying Patient #2's electronic medical chart. During an interview on 05/13/2026 at 10:55 AM, Medical Doctor (MD) #1 stated that staff should lock their laptops to maintain privacy and prevent violation of the Health Insurance Portability and Accountability Act (HIPAA).