General Manual Master Form - Microsoft Word
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GENERAL MANUAL – POLICY/PROCEDURE Effective Date: October, 2005 Reviewed: Revised: September, 2010 Issued By:Senior Management/Health Records Committee/Medical Advisory Committee Approved by:- General Counsel Title:- RETENTION AND STORAGE OF RECORDS Policy Number: I-i-35-48 Key Words: Health Records, Retention, Storage, Records Stakeholders: Patients, Staff Policy Statement: Purpose It is the purpose of this policy to ensure that Mount Sinai Hospital records are retained and stored in a reasonably secure manner and in accordance with legal requirements. Definitions A “record” is any information received and/or created in the course of Hospital operations, in any form or media, including written, printed, photographic or electronic form, but excluding computer programs and other mechanisms that produce a record. An “official custodian” has been assigned to each type of record in this policy. This identifies the department, unit or individual that has responsibility for the storage and maintenance of documents and other materials in accordance with this policy. Procedure 1. All records created, captured and managed within Mount Sinai Hospital must be maintained in accordance with the applicable period set out in the Mount Sinai Hospital Records Retention & Disposal Schedule set out in Appendix 1. 2. Retention periods are based on applicable legal statutes, professional regulations, generally accepted industry practices and established Mount Sinai Hospital policies. 3. In the absence of any of the above, records are kept for as long as required by the purpose for which the information in the record was collected. 4. Records shall not be kept for any longer than set out in the Retention & Disposal Schedule or as consented to by the patient unless for the purposes of managing legal risks with the approval of the Office of Risk Management or if the Hospital receives notice of a court action, investigation, assessment, inspection, inquest, access request or other inquiry prior to the record’s destruction. All non-clinical records of an administrative nature that have not been addressed in the Schedule should be retained for a period of no more than two years. 5. Multiple copies of a single record should not be kept as such a practice increases the chances of unauthorized use and disclosure of confidential information, places an undue financial burden on the Hospital and results in an inefficient use of space. 6. During the retention period, records must be stored securely by providing adequate physical security, 1/14 GENERAL MANUAL – POLICY/PROCEDURE Effective Date: October, 2005 Reviewed: Revised: September, 2010 Issued By:Senior Management/Health Records Committee/Medical Advisory Committee Approved by:- General Counsel Title:- RETENTION AND STORAGE OF RECORDS technological security and administrative controls to protect against unauthorized use and disclosure and the record being lost or stolen. 7. Physical controls may include but are not limited to locked filing cabinets, restricted office access and a manned reception area to control physical access to a records storage area. 8. Technological security may include but is not limited to intruder detection systems, password protecting documents and encryption. For more information, please refer to the Appropriate Use of Technology and Information Security policies. 9. Administrative controls may include but are not limited to prohibiting anyone without an MSH badge from the records storage area, appointment of a staff member with responsibility for your area’s security, training on your security measures, confidentiality agreements for outside vendors and auditing of access to electronic records. 10. The adequacy of any particular security measure is based on the sensitivity of the information and the risks to which it is exposed. 11. Any storage facilities used for long-term storage of records should have adequate security and climatecontrol standards. If the facilities of an outside agency are used, these requirements should be specified in the contract. Staff may access the Corporate Privacy Officer to ensure these requirements are appropriately addressed in any storage agreement. 12. All Mount Sinai Hospital records stored electronically shall be subject to an automatic back-up for file recovery purposes to protect records from loss or damage. 13. All Mount Sinai Hospital records shall be disposed of in accordance with the Secure Disposal of Confidential Information policy. In respect of all disposed of Hospital health records the names of the patients to whom the records relate and the date and manner of destruction shall be recorded. 2/14 Appendix 1 Corporate Records Type of Record Agreements/Contracts Leases/Deeds Hospital Annual Report Record Format Retention Period Official Custodian Statute/Regulation Hard Copy Hard Copy Hard Copy Permanent Permanent Permanent Responsible V.P. CFO President & CEO, VP for Communications Limitations Act s. 4 and s. 15 Limitations Act s. 4 and s. 15 Hard Hard Hard Hard Copy Copy Copy Copy Permanent Permanent Ten Years Permanent President President President President Hard Copy Permanent Patient Relations Administrative By-Laws Medical Staff By-Laws Hard Copy Hard Copy Permanent Permanent Executive Correspondence Hard Copy Insurance Policies Minutes: Board of Directors Hard Copy Date of correspondence plus minimum 2 years up to 15 years. Depending on the policy President & CEO Senior Vice President, Medical Senior Management Corporations Act s. 300 Corporations Act s. 300 Corporations Act s. 300 Corporations Information Act s. 5(2) Corporations Act s. 300 Limitations Act s. 4 and s. 15 Corporations Act s. 300 Corporations Act s. 300 Hard Copy Committees Documents: Documents of Incorporation Register of Directors Register of Members Notices under the Corporations Information Act Policies & & & & CEO CEO CEO CEO Limitations Act s. 4 and s. 15 CFO Limitations Act s. 15 Permanent Corporate Secretary c/o M. Harpur Hard Copy Permanent Standing Board Committees Hard Copy Permanent Members’ Meetings Hard Copy Permanent CFO Corporate Secretary c/o M. Harpur Senior Management Lead Corporate Secretary c/o M. Harpur Corporate Secretary c/o M. Harpur Corporations Act s. 299(1) and s. 304 Income Tax Act Regulations s. 5800(a) Corporations Act s. 299(1) and s. 304 3/14 Corporations Act s. 299(1) and s. 304 Corporations Act s. 299(1) and s. 304 Type of Record Record Format Retention Period Official Custodian Senior Leadership Committee Hard Copy Permanent President & CEO Quality and Risk Management Litigation Files Hard Copy 7 Years Risk Management/ Legal Services Medical Advisory Committee: Meeting Minutes Hard Copy Permanent Subcommittee Minutes Hard Copy Permanent Senior Vice President, Medical Senior Vice President, Medical 4/14 Statute/Regulation Corporations Act s. 299(1) and s. 304 Corporations Act s. 299(1) and s. 304 Corporations Act s. 299(1) and s. 304 Financial Records Type of Record General Annual Financial Statements Record Format Retention Period Official Custodian Hard Copy Permanent Finance Special Contracts or Agreements necessary to understanding general ledger entries General Journal Hard Copy Permanent Finance Hard Copy Permanent Finance General Ledger Hard Copy Permanent Finance Source Documents (i.e. records integral to the creation of financial statements and tax returns) Bank Reconciliation Statements Hard Copy Six (6) years from the end of tax year (fiscal period) to which they relate Finance Hard Copy 10 Years Finance Bank Statements Hard Copy 10 Years Finance Cancelled Cheques Hard Copy 10 Years Finance Cheque Register Hard Copy Permanent Finance Duplicates of Charitable Donations Receipts (Other than 10 Year Gifts) Hard Copy Two years from end of calendar year to which they relate Finance 5/14 Statute/Regulation Income Income s. 5800 Income Income s. 5800 Tax Act s. 230(1) Tax Act Regulations Tax Act s. 230(1) Tax Act Regulations Income Tax Act s. 230(1) Income Tax Act Regulations s. 5800 Corporations Act s. 302 Income Tax Act s. 230(1) Income Tax Act Regulations s. 5800 Corporations Act s. 302 Income Tax Act s. 230(1) Income Tax Act Regulations s. 5800 Income Income s. 5800 Income Income s. 5800 Income Income s. 5800 Income Income s. 5800 Income Income s. 5800 Tax Act s. 230(1) Tax Act Regulations Tax Act s. 230(1) Tax Act Regulations Tax Act s. 230(1) Tax Act Regulations Tax Act s. 230(1) Tax Act Regulations Tax Act s. 230(1) Tax Act Regulations Type of Record Donation Records (10 Year Gifts) General Ledger Interface: Accounts Payable Receipts Record Format Hard Copy Retention Period Two years after revocation of charitable registration Official Custodian Finance Income Tax Act s. 230(1) Income Tax Act Regulations s. 5800 Income Income s. 5800 Income Income s. 5800 Tax Act s. 230(1) Tax Act Regulations Income Income s. 5800 Income Income s. 5800 Income Income s. 5800 Income Income s. 5800 Tax Act s. 230(1) Tax Act Regulations Income Income s. 5800 Income Income s. 5800 Tax Act s. 230(1) Tax Act Regulations Hard Copy 10 Years Finance Hard/Electronic Copy 7 Years Finance Hard/Electronic Copy 7 Years Payroll T4/T4A Reports Hard Copy/Disk 7 Years Payroll Time Sheets Hard/Electronic Copy 7 Years Payroll Deduction Register Electronic Copy 7 Years Payroll Patient Accounts: Patient Ledger Card Hard Copy 7 Years Finance Cash Receipts Register Hard Copy 7 Years Finance Grant Accounts Payroll: Payroll Register 6/14 Statute/Regulation Tax Act s. 230(1) Tax Act Regulations Tax Act s. 230(1) Tax Act Regulations Tax Act s. 230(1) Tax Act Regulations Tax Act s. 230(1) Tax Act Regulations Tax Act s. 230(1) Tax Act Regulations Type of Record Record Format Retention Period Official Custodian Statute/Regulation Cash Receipts Hard Copy 10 Years Finance Customer Invoices Hard Copy 7 Years Finance Other Billing Invoices Hard Copy 7 Years Finance Bank Reconciliation Statements Hard Copy 10 Years Finance Bank Deposit Slips/Books Hard Copy 10 Years Finance Patient Valuables Envelopes/Security Register Hard Copy Intercon Security policy requires: 7 Years Security Hard Copy 10 Years Finance Income Tax Act s. 230(1) Income Tax Act Regulations s. 5800 Hard/Electronic Copy Permanent Finance Hard Copy Permanent Finance Income Income s. 5800 Income Income s. 5800 Revenue Journals: Accounts Receivable Revenue Reports and Worksheets Miscellaneous Accounting Records Aging Analysis Profit and Loss Reports 7/14 Income Tax Act s. 230(1) Income Tax Act Regulations s. 5800 Income Tax Act s. 230(1) Income Tax Act Regulations s. 5800 Income Tax Act s. 230(1) Income Tax Act Regulations s. 5800 Income Tax Act s. 230(1) Income Tax Act Regulations s. 5800 Income Tax Act s. 230(1) Income Tax Act Regulations s. 5800 Private Security and Investigative Services Act Regulation 434 Tax Act s. 230(1) Tax Act Regulations Tax Act s. 230(1) Tax Act Regulations Type of Record Record Format Retention Period Official Custodian Statute/Regulation Budget and Bad Debt Analysis Hard Copy Permanent Finance Income Tax Act s. 230(1) Income Tax Act Regulations s. 5800 Procurement Records Related to the selection of supplier: Scanned Copy 7 Years Contract Management Broader Public Sector Procurement Directive, April 1 2010 8/14 A copy of the procurement justification or the business case Information regarding all supplier consultations, including any requests for information, undertaken in the development of the procurement business case and/or procurement documents; Evidence that all required approvals were obtained; Copies of all procurement documents used to qualify and select the supplier; Where the procurement was conducted through a VOR arrangement, information regarding the second-stage selection process used to select the particular vendor of record; Where the procurement was single or sole sourced, documented justification, applicable exemptions and associated approvals; Copies of all advertisements of procurement documents; Copies of all successful and unsuccessful responses, submissions, proposals and bids received in response to procurement documents, including the conflict-of-interest declaration and other attached forms; Information regarding any issues that arose during the procurement process; Information regarding all evaluations of submissions, proposals and bids received in response to procurement documents; Information regarding all vendor debriefings including written documentation of the offer of vendor debriefing; Copies of all award letters, notices and posted announcements; Information regarding all changes to the terms and conditions of the Agreement, including any changes that resulted in an increase in the Agreement price; Risk assessment information and recommendations, where applicable; Information regarding all protests, disputes or supplier complaints regarding the procurement, including disputes with respect to the Agreement contents Copies of the Agreement See above for hard copy of agreement under “Corporate Records” Related to the management of the successful Vendor / resulting Agreement: 9/14 Information regarding the management of the supplier, including how the supplier’s performance was monitored and managed and, where applicable, mechanisms used to transfer knowledge from the supplier to organization staff; Contractor screening decisions, where applicable; Evidence of receipt of deliverables. Scanned Copy in Contract Management System Scanned Copy 7 Years Contract Management and General Counsel Broader Public Sector Procurement Directive, April 1 2010 7 years Contract Owner Broader Public Sector Procurement Directive, April 1 2010 Payroll/Human Resources Records Type of Record Employee Records: Canada Pension Plan Contributions Designated Substance Exposure Records Record Format Official Custodian Payroll Hard Copy Six years following the year for which they are kept 40 Years Employees’ Earning Record Cards Employer’s Report of Injury/ Disease (Form 7) General Employment Records Hard Copy/ Electronic Copy Hard Copy Six years following the year for which they are kept 40 Years Payroll Hard Copy 3 years after creation date HOOPP Records Individual Contributions Electronic Copy 7 Years Human Resources/ Payroll Income Tax/T4 Forms Hard Copy/Disk 7 Years Payroll Occupational Health and Safety Records EHT Records/Billing Forms Hard Copy 40 Years Hard Copy 7 Years Occupational Health and Safety Payroll Payroll Deduction Authorization Forms Hard Copy 7 Years Human Resources/ Payroll Payroll Journal Sheets Hard/Electronic Copy 7 Years Payroll 10/14 Electronic Copy Retention Period Occupational Health and Safety Occupational Health and Safety Human Resources Statute/Regulation Canada Pension Plan (Canada) ss. 24(2) Limitations Act s. 4 and s. 15 Ministry of Labour Employment Insurance Act (Canada) ss. 87(3) Workplace Safety and Insurance Act s. 80 Employment Standards Act s. 15(5) Income Tax Act s. 230 Income Tax Act Regulations s. 5800 Income Tax Act s. 230 Income Tax Act Regulations s. 5800 Limitations Act s. 4 and s. 15 Income Income s. 5800 Income Income s. 5800 Income Income s. 5800 Tax Act s. 230 Tax Act Regulations Tax Act s. 230 Tax Act Regulations Tax Act s. 230 Tax Act Regulations Type of Record Record Format Retention Period Official Custodian Time Cards/Sheets Hard/Electronic Copy 7 Years Payroll EI Records Hard Copy 7 Years Payroll Union Dues Deduction Sheets Hard/Electronic Copy 7 Years Payroll WSIB Invoices Hard Copy 7 Years Payroll Minutes of Joint Health and Safety Committee Material Safety Data Sheet Electronic Copy Current Year plus Minimum 6 years Hard Copy Credentials/Medical Staff Files Hard Copy Date of Expiry plus Minimum 2 Years Permanent Occupational Health & Safety Occupational Health & Safety Senior Vice President, Medical 11/14 Statute/Regulation Income Tax Act s. 230 Income Tax Act Regulations s. 5800 Employment Insurance Act s. 87(3) Income Tax Act s. 230 Income Tax Act Regulations s. 5800 Income Tax Act s. 230 Income Tax Act Regulations s. 5800 Limitations Act s. 4 and s. 15 Limitations Act s. 4 and s. 15 Limitations Act s. 4 and s. 15 Quality and Risk Management Records Type of Record Quality and Risk Management Reports: Patient/Visitor Incident Report Accreditation Survey Recommendations Patient Concerns NRC Picker Patient Satisfaction Survey Results Disaster Plans 12/14 Record Format Retention Period Official Custodian Statute/Regulation Electronic and/or Hard Copy Hard/Electronic Copy 7 Years Risk Management Corporate Policy 7-10 Years N/A Electronic and/or Hard Copy Hard/Electronic Copy Permanent President & CEO, and Quality and Performance Management Patient Relations N/A Intranet and Hard Copy 10 Years Quality and Performance Management Risk Management 7-10 Years Corporate Policy Corporate Policy Patient Care Records and Other Materials NOTE: RECEIPT OF A COURT ORDER OR NOTICE OF MOTION SUPERCEDES THIS RETENTION PERIOD. NO PATIENT RECORD MAY BE DESTROYED IF SUCH A DOCUMENT HAS BEEN RECEIVED. Type of Record Patient Register - Patient - Out-Patient - Emergency - Operating Room - Health Records for inpatients, day surgery, emergency and medical daycare patients Record Format Retention Period Official Custodian Statute/Regulation Hard Copy 50 Years Health Records Limitations Act s. 4 and s. 15 Microfiche or micro roll for records from 1953 – 1991 28 Years from the last visit Health Records Public Hospitals Act Regulation 965 20(3) Adult (18 years and older) At Least 5 Years After Day on Which the Image is Created. Medical Imaging Public Hospitals Act Regulation 965 20(4)(a) Paper only from 1992 to August 15, 2004 Diagnostic Images (excluding mammograms) Diagnostic Images (Mammograms) Dual electronic and paper formats after August 15, 2004 Electronic or Hard Copy Electronic or Hard Copy Children (Less than 18 Years) At Least 5 Years After the Patient’s 18th Birthday. Adult (18 years and older) At Least 10 Years After Day on Which the Image is Created. Children (Less than 18 Years) At Least 10 Years After the Patient’s 18th Birthday. 13/14 Public Hospitals Act Regulation 965 20 (4)(b) Medical Imaging Public Hospitals Act Regulation 965 20(5)(a) Public Hospitals Act Regulation 965 20(5)(b) Type of Record Dental X-Rays Pharmacy Records: Controlled Drug Records Inpatient and Outpatient Record Format Retention Period Official Custodian Statute/Regulation Hard Copy 10 Years Dentistry Hard Copy 2 Years Pharmacy Controlled Drugs and Substances Act s. 63(b) Narcotic Records Inpatient and Outpatient Inpatient and Outpatient Prescriptions Record of Inpatient Dispensing Hard Copy 2 Years Pharmacy Electronic Copy 2 Years Pharmacy Drug and Pharmacies Regulation Act s. 156(2) Drug and Pharmacies Regulation Act s. 156(2) Patient Profile – Inpatient Copy of Physicians’ Orders Electronic Copy Hard Copy Pharmacy Pharmacy Limitations Act s. 4 and s. 15 Cash Register Receipts Drug Store Communications: Paging Records Hard Copy Permanent Year of Record plus Minimum Two Years 7 Years Pharmacy Income Tax Act s. 230 Hard Copy 28 Years Telephone & Telecommunications Corporate Policy Hard Copy Hard Copy Electronic Copy 28 Years 28 Years 28 years Nursing Nursing Nursing Corporate Policy Corporate Policy Per K. Parker Hard Copy 15 Years Various Clinical Areas Nursing Unit Records: Assignment Sheets Work Schedules WIPS Documentation: Minutes of Committees Relating to Patient Care (Other than Standing Committees of the Board) The retail out-patient pharmacy closed as of October, 2008. 14/14
