Record Retention and Destruction Policy

Transcription

1 Policy North York General Hospital (NYGH) will retain and dispose of records in accordance with applicable laws and policies including the Personal Health Information Privacy Policy. Retention Records of all types, including Personal Health Information, will be retained as long as is necessary according to applicable legislation or longer if needed. Records will be retained in secure locations appropriate to the sensitivity of the information. Destruction Records of all types, including Personal Health Information, will be destroyed according to this policy once the retention period has been reached. North York General Hospital will dispose of records in accordance with applicable laws and policies. Destruction of hard copy documents including Personal Health Information will be completed through fine shredding or incineration. Destruction of electronic documents, excluding Personal Health Information, will be completed in accordance with current, IT approved, processes which ensure that the data cannot be retrieved. A log of all records destroyed must be maintained regardless of whether the record is in hardcopy or electronic form. Related Documents Personal Health Information Privacy Policy Definitions Personal health information (PHI) means identifying information about an individual in either oral or recorded form if the information: Relates to the physical or mental health of the individual including medical (family) history; Relates to providing health care to the individual; Is a plan of service under the Long-Term Care Act, 1994; Relates to payments or eligibility for health care; Relates to donation of a body part or bodily substance of an individual or derived from testing or examination of any such body or bodily substance; Is the individual s health number; Page 1 of 15

2 Identifies the hospital as the provider of health care to the individual or Substitute Decision Maker. (Bill 31, Personal Health Information Protection Act, section 4) 1 Employee Record means Attendance Records, Correspondence, and Employee Documents including the letter of offer, resume/application form, name, address, telephone number, social insurance number, date of birth, next of kin/person to notify in an emergency, Personnel Action Forms indicating salary, status revisions and dates, professional/technical registration numbers, copies of all correspondence, performance appraisals, outline of employment benefits and applicable documents, Statement of Confidentiality. 2 Policy Details 1.0 Retention 1.1 Patient Care Records 1.2 Original Hardcopy Health Records where an electronic copy is available (i.e. original is scanned into the Electronic Health Record) 1.3 Records associated with Unit/Program Operations 1.4 Incident Reports & Patient Complaints 1.5 Corporate/Administrative Records 1.6 Financial Records 1.7 Human Resources Records 2.0 Destruction 2.1 Hardcopy Records 2.2 Original Hardcopy Health Records where an electronic copy is available 2.3 Electronic Records 1 Definition from the Protection of Personal Health Information policy 2 Definition from the Employee Records policy North York General Hospital Page 2 of 15

3 1.0 Retention of Records If before the end of the retention period, we receive notice of a court action, or of an investigation, assessment, inspection, inquest or other inquiry from a professional College, the Medical Review Committee, or the Coroner, relating to the treatment of a patient previously cared for at NYGH, or an investigation by a financial regulatory body, we will retain the applicable records until, the action, assessment or inquest is complete. This additional retention requirement must be noted by that area receiving notice of this action, assessment or inquest. For patient records, this information will be retained by the Health Information Management Program once notified by the area receiving the notice. 1.1 Patient Care Records Type of Information Age of Patient/Criteria Minimum Retention by law Statute or Regulation NYGH Retention Rule Master Patient Index (record of all NYGH visits) All patients Public Hospitals Act Reg 965 North York General Hospital Page 3 of 15

4 Health Record 3 (including Diagnostic Imaging Exam of the Breast) In-Patient or Outpatient who is 18 years or older In-Patient/Out-patient who is less than 18 years old 10 years after discharge or death of the patient 10 years after the 18 th birthday of the patient Public Hospitals Act Reg 965 Public Hospitals Act Reg Years Release of Information Requests 10 yrs, or 10 yrs from pt 18 th birthday As long as the record is kept Public Hospitals Act Reg years Patient records for research subjects of Clinical Trials All patients in a clinical trial 25 years from termination of the study Guidance for Records Related to Clinical Trials *** 4 28 Years Diagnostic Imaging Record of a patient, excluding imaging exam of the breast. Patient is 18 years old or older 5 years after the day on which the diagnostic imaging record is created Public Hospitals Act Reg years Patient is under 18 5 years after the 18 th birthday of Public Hospitals Act 5 years from the patient s 18 th 3 We are not required to retain any videotape of a diagnostic imaging examination or test of a patient unless the videotape constitutes the only diagnostic imaging record of the examination or test 4 Guidance for Records Related to Clinical Trials (GUIDE-0068) North York General Hospital Page 4 of 15

5 years of age the patient Reg 965 birthday 1.2 Original Hardcopy Health Records where an electronic copy is available (i.e. original is scanned into the Electronic Health Record) Type of Information Age of Patient/Criteria Minimum Retention by law Statute or Regulation NYGH Retention Rule Health Record (all or portions thereof) Not applicable Not Applicable None 6 months 1.3 Records associated with Unit/Program Operations Type of Information Age of Patient/Criteria Minimum Retention by law Statute or Regulation NYGH Retention Rule Pharmacy Dispensing Records Not applicable 2 years after drug is dispensed or when records are destroyed Log Books/Sheets Not applicable Not specified None Drugs and Pharmacies Regulations Act 3 Years North York General Hospital Page 5 of 15

6 Daily checklists of patients Not applicable Not specified None 1.4 Incident Reports, Patient Complaints, Risk Management Records Type of Information Minimum Retention Statute or Regulation NYGH Retention Rule Incident Reports Not specified None 3 years Patient Feedback (Complaints and Compliments) Not specified None 3 years Potential Claims (no progress) Not specified None 7 years Claims Not Specified None 5 years after close of claim 1.5 Corporate/Administrative Records Type of Information Minimum Retention Period North York General Hospital Page 6 of 15

7 Documents of Incorporation Agreements Contracts Deeds, Leases Board Policies Board By-Laws Accreditation Records Annual Reports Board Member Lists Board Minutes Board Committee Minutes Strategy Team Minutes North York General Hospital Page 7 of 15

8 Health & Safety Committee Corporation Member List Medical Advisory Cmt Patient Care Quality Committee Health Records Cmt Pharmacy & Therapeutics 10 Years 10 Years 10 Years 10 Years 10 Years Other Clinical/Patient Care Committees 10 Years Other administrative Committees Policies 10 Years 28 Years North York General Hospital Page 8 of 15

9 All financial records must be kept for a minimum of 2 years from the date of dissolution of a corporation. (Income Tax Act) 1.6 Financial Records Type of Information Minimum Retention Comments Statute or Regulation General Audited Financial Statements Annual Financial Returns Financial Annual Statements General Ledger Journal Entries Year End Audit Working File 20 years Cheque Register 7 yr Cash Receipts Register 7 yr Payroll Register 7 yr North York General Hospital Page 9 of 15

10 Income Register 7 yr t-4 Slips 7 yr Internal Financial Reports 7 yrs Revenue Including AR Revenue Journals 7 yr OHIP Billing Information 28 years Based on Patient Record Retention rule. Health Insurance Act. Patient s Ledger Cards 7 yr Cash Receipts 7 yr Midnight Census 3 yr Patient Charge Slips 1 yr Keep until year end audit Daily Cash Work Sheets 1 yr Keep until year end audit Bank Deposit Slips or Books 7 yr North York General Hospital Page 10 of 15

11 Central Supply Room Central Supply Requisitions 1 yr Check Slips 1 yr Accounts Payable AP Journal 7 yr Copy of check voucher 7 yr Copy of cheque 7 yr Cancelled Cheques 7 yr Bank Statements 7 yr Bank Reconciliations 7 yr Sub-Ledger 7 yr Land Acquisition Invoices Business Corporations Act Capital Equipment Records 20 years North York General Hospital Page 11 of 15

12 Purchasing Department Requisition 5 yr Copy of PO Supplies 2yr Copy of PO Capital 10 yr Quotations & Correspondence 5 yr Packing Slips 1 yr 1.7 Human Resources Records Type of Information Minimum Retention Comments Statute or Regulation Employee Record 3 yrs After employee terminates. If employee is under 18, 3 years after 18 th birthday. Time Cards/Records 3 yrs After work is performed or employee terminates Employee earning record 3 yr After work is complete Employment Standards Act Canada Labour Code Canada Labour Code North York General Hospital Page 12 of 15

13 Payroll deduction authorization records OHIP deduction records, billing records 7 yrs From termination or revocation of authorization 7 yrs Canada Labour Code Exemption records 7 yrs From termination of employee HOOPP Records, individual employee deductions Income tax copies of T-4 Slips Union Dues Deduction Records Employment Insurance Records General Employment Records ly Ontario Pension Benefit Act 7 yrs 7 yr Except where collective agreement states otherwise 7 yrs From date of Certification of Inspection by EI Commission 3 years From date work is completed. Employee Standards Act Occupational Health & Safety North York General Hospital Page 13 of 15

14 Material Safety Data Sheet Until expiry of data sheet (3 years from issuance) Must be updated every 3 yrs or within 90 days of new release Canada Labour Code/ Employee Standards Act Employee Education Program 2 yrs After employee stops working with the particular substance or work area. Canada Occupational Safety and Health Regulations Occupational Health Records 10 yrs From termination of employment Inspection Reports, Ministry of Labour Investigative Reports on Hazardous Substances Annual Workplace Inspections Accident/Injury Incident Reports Worker s Compensation Board Invoices 10 yrs Keep past 2 reports Keep past 2 reports 3 yrs 2 yrs No statutory provisions however the Board may request previous records. North York General Hospital Page 14 of 15

15 NYGH POLICY & PROCEDURE NUMBER: V-50 Record Retention & Destruction CROSS REFERENCE: Personal Health Information Privacy, V Destruction Procedure 2.1 Hardcopy Records Hardcopy records which have passed the NYGH Retention time period and where there is no additional reason to maintain the record for a longer period of time will be destroyed. The Director of the area wishing to destroy the records must approve the destruction prior to commencing the procedure. The destruction of any Personal Health Information must be completed in collaboration with the Director of HIM, or designate. A log must be kept, recording a detailed description of the records destroyed including the date, time, method of destruction and the identity of the individual whose records are being destroyed Records of PHI: Patient name, DOB, NYGH Unique Number & Visit number, Visit Date HR Records: Employee Name, Number and termination date Financial Records: Fiscal year or pay period, as applicable The completed log must be signed and dated by the Director of the Program responsible for destroying the records. All Personal Health Information destruction records must be co-signed by the Director of HIM, or designate. The log must be kept permanently in a secure location. Hardcopy records must be finely shredded or incinerated by an NYGH approved record destruction company. 2.2 Hardcopy Health Records where an electronic copy is available Hardcopy records of Personal Health Information which has been microfilmed, scanned or printed from an electronic system will be destroyed by fine shredding or incineration immediately following fulfillment of the purposes for which it was printed and/or produced. Patient level detail logs are not required since we are destroying a copy of the document. The electronic copy of the document replaces the hardcopy as the original document. 2.3 Electronic Records Electronic records which have passed the NYGH Retention time period shall not be destroyed in order to provide a comprehensive longitudinal view of the patient s history in accordance with the current Healthcare system view of maintaining a lifelong health record. Page 15 of 15