Document Management/Archiving Records general guidelines for the UBC Department of Medicine

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1 Dcument Management/Archiving Recrds general guidelines fr the UBC Department f Medicine ADMINISTRATIVE/FINACIAL FILES: /Crrespndence - An extremely difficult recrd type t schedule, sme is clearly imprtant, even evidential, while sme may be deleted immediately. It is recmmended that recrds that are infrmatinal r transient in nature (general annuncements, ntice f events, reminders, etc ) be deleted nce read. This will include spam, persnal crrespndence, and ther nn-ubc crrespndence. Recrds f an evidential nature (prviding evidence) shuld be printed and filed accrding t the subject t which they relate, r saved in an equivalent electrnic flder. Crrespndence may relate t existing files - student, persnnel, financial, etc... - And if s, shuld be filed in the file t which it relates. It will be then retained as lng as the file is scheduled t be retained. Fr example, crrespndence related t a particular financial matter, if cnsidered evidential, shuld be filed with the financial file and retained fr current year + 6 years. In the interests f clarity, recrd keepers shuld cnsider crrespndence as cnstituting bth hard cpy and electrnic frms. Crrespndence will be ne f three types: Archival/Executive (vital recrd) - This series dcuments significant events and the develpment f administrative structure, plicies, and prcedures f this ffice. It may als recrd the histrical develpment f the ffice. Recrds may include: letters sent and received; ntes; directives; acknwledgments; and memranda. Crrespndence may be intra-ffice, within UBC, and with nn-ubc agencies, rganizatins, and individuals Recmmended retentin perid - Retain in Department fr 5 years. - Send t University Archives fr permanent preservatin. General/Administrative Recrd- Series dcuments cmmunicatins received r sent which cntain significant infrmatin abut an institutin's prgrams. Recrds include letters sent and received, memranda, ntes, enclsures, and attachments. Retain in Department fr 5 years r until subject t which it relates is superseded/bslete, whichever is lnger. - Destry Ephemera (Junk) - Series dcuments cmmunicatins received r sent which d nt cntain significant infrmatin abut an institutin's prgrams. Recrds include, but are nt limited t, advertising circulars, drafts and wrksheets, desk ntes, memranda, and ther recrds f a preliminary r infrmatinal nature. May als include letters sent and received; ntes; acknwledgments; cmmunity affair ntices; charity fund drive recrds; rutine requests fr infrmatin r publicatins; enclsures and attachments. This recrd series may als include unslicited crrespndence (spam). Destry nce superseded/bslete - these recrds shuld seldm be either printed (frm electrnic) r scanned (frm hardcpy), but rather, retained in their riginal frm until destryed.

2 Recrd Type Retentin Perid Dispsitin Ntes Crrespndence Executive - 5 Year UBC Archives See abve fr detailed ntes - print t paper Crrespndence Administrative - 5 year Destry See abve fr detailed ntes - print t paper Crrespndence General/Ephemeral - when S/O Destry See abve fr detailed ntes - print t paper Limited Financial backup - If certain that primary recrds are maintained by Finance, these recrds shuld be destryed when superseded r bslete - that is, recrds shuld be retained until summarized mnthly/annually r n lnger needed fr nging business. Limited HR backup - Destry when superseded r bslete (seven years after the terminatin date) if certain that primary recrd is held elsewhere. Prir t the destructin f files, separate any recrds related t cmmendatins and fficial recgnitin f exceptinal perfrmance, and cntact University Archives t ensure apprpriate retentin f these recrds. If recrds are f a supplementary nature t the HR files lcated within either Medicine r Central HR, they shuld be merged with that file. (This is fr nn- Faculty files staff and student files) Meeting/Cmmittee management - Many units/persns at UBC will retain a great deal f material relating t cmmittees they sit n, and meetings they attend. Fr retentin purpses it is imperative that we understand wh has respnsibility fr preservatin f these recrds. Department f Medicine Cmmittees - VITAL RECORDS Cmmittees cncerning the Department f Medicine and its functins, including thse related t appintment f staff and faculty, curriculum, initiatives, and special prjects may cntain minutes, agendas, supprting dcuments including riginal membership, surveys, interim r final reprts and ther relevant infrmatin that dcuments the activities f the cmmittee. As the single mst imprtant recrd type prduced by the University, it is imperative that these recrds f decisin making find their way t the University Archives fr permanent preservatin. Recrd Type Retentin Perid Dispsitin Ntes Rutine annual cmmittee minutes, agendas, reprts, final dcuments Retain until superseded/bslete UBC Archives Recrds in this categry shuld be cnsidered as rutine - examples might include Fire Safety r Fundraising - Print electrnic recrds t paper Recrd Type Retentin Perid Dispsitin Ntes

3 Department f Medicine Cmmittee minutes, agendas, reprts, final dcuments 5 years UBC Archives Recrds in this categry are cnsidered vital recrds - will include recrds related t Curriculum, Finance, Searches, and ther decisin making- Print electrnic recrds t paper University Cmmittees Minutes and ther material frm the Bard f Gvernrs and the Senate, as well as President s Advisry Cmmittees and ther Ad Hc Cmmittees are ften distributed widely. If the minutes, r the subject t which it relates directly cncerns the Department f Medicine, recrds shuld be retained fr five years then destryed. If the recrds are simply infrmatinal in nature, they shuld be retained fr ne year r until superseded then destryed. External Cmmittees Again, sme external minutes will relate directly t the Department while thers will be simply infrmatinal in nature. It is unlikely that all minutes need t be kept and likely nly the mst recent versin need be. Still, as a minimum, recrds shuld be kept fr ne year. D nt destry until it is clear what value recrds hld. Official Letters - Award, Discipline, etc As a general rule, such dcuments shuld have bth a lengthy retentin perid and secure strage. Mst fficial letters including award and discipline need t be retained fr seven years after the terminatin date as these recrds becme part f the emplyee s Department file. This series will require cnsultatin s prir t destrying any recrds, cntact University Archives t ensure prper retentin. Outside (nn-ubc) interests - Persnal research, schlarly reviews, etc - These are nt UBC recrds and shuld be retained accrding t the Head s needs. Scheduling - Recrds shuld be retained fr ne year. Recrds f a summary nature - appintment bks, day-timers, rganizers and calendars, etc - may be sent t Archives as a recrd f activity. Recrd Type Retentin Perid Dispsitin Ntes Scheduling/Appintment recrds 1 year after event destry Recrds f a summary nature - appintment bks, day-timers, rganizers and calendars, etc - may

4 be sent t Archives as a recrd f activity. Department Internal/External Cmmunicatins Annual Reprt - A cmplete set shuld be kept in ffice, and a duplicate hardcpy sent t the University Archives. Divisinal Review - Retained in ffice until superseded by a mre recent review - superseded hardcpy sent t the University Archives. Prjects Initiatives - Prject files related t and prviding evidence f initiatives undertaken within the administrative ffice. Recrds shuld be retained in ffice until n lnger needed fr business. They can then be culled f reference material and wrking dcuments. Final reprts, recmmendatins, minutes, crrespndence, and ther material relating t the final utcme f the prject shuld be sent t University Archives. Recrd Type Retentin Perid Dispsitin Ntes Prject Recrds Perid prject active + 1 year UBC Archives cull reference material and wrking dcuments Planning Recrds prvide evidence f decisin making within the Department, and may invlve annual, three-year and five-year crprate plans, and planning f general and specific bjectives fr administrative units (See CREPUQ 01.21) Retain fr ne year after time perid t which plans relate, then cull reference material and wrking dcuments. Minutes, final reprts, recmmendatins, crrespndence, and ther material relating t the implementatin r final utcme f the plan shuld be sent t University Archives. Recrd Type Retentin Perid Dispsitin Ntes Planning Recrds Planning perid + 1 year UBC Archives cull reference material and wrking dcuments PERSONNEL FILES: Searches - Unsuccessful Staff and Faculty applicant files may be destryed after 1 year. Successful applicant files shuld be retained in their entirety fr three years. Successful applicant files may be retained lnger at the discretin f the ffice. These recrds cntain persnal infrmatin and require adequate security. Mst successful applicant material may be included in persnnel file. Successful Staff, M&P, and Faculty searches - destry after three years. President, Vice President, Dean, Directr s search recrds shuld be retained in ffice fr length f appintment. Recrd Type Retentin Perid Dispsitin Ntes Search - Staff, Unsuccessful Applicants Destry Minimum f 1 year after the appintment prcess has been cmpleted Unslicited applicatins s nt need t be retained and can be destryed at the discretin f the Department

5 Search Faculty, Unsuccessful Applicants Search - Staff, Successful Applicants Minimum f 2 years after the appintment prcess has been cmpleted 7 years after the terminatin date Destry Destry Unslicited applicatins s nt need t be retained and can be destryed at the discretin f the Department The applicatin file (including Resume/CV) and the appintment letter f the successful applicant becmes part f the Department emplyee file. Freign hires may have further retentin requirements cntact UBC HR Faculty Files - Fr backgrund see UBC Archives - The Department must retain Faculty files in ffice seven years after the terminatin date. Hwever, units may, fr administrative purpses, keep them lnger. T define retentin requirements fr the Department, cnsultatin is needed. RESEARCH FILES: Grant apprval - Recmmended retentin varies depending n the surce f the funds and wh the Office f Primary Respnsibility (OPR) is. Recrd Type Retentin Perid Dispsitin Animal Care Cmmittee Files Permanently by Research Services they are held in the ffice while current, then placed in strage Human Ethics Cmmittee Files Cmmittee Files Grant Applicatins Grant Accunts Other ffices hlding cpies Permanently by Research Services Other ffices hlding cpies Held by Research Services while the Researcher is emplyed by the University, plus three years Other ffices hlding cpies Recrds f successful applicatins are retained by Research Services while the research prject is nging, plus three years; thse f unsuccessful applicatins are retained fr tw years. Other ffices hlding cpies f these recrds shall Retained by Research Services retain while current, plus ne year, then destry they are held in the ffice while current, then placed in strage retain while current, plus ne year, then destry Held in the ffice while current, and then placed in strage. retain while current, plus ne year, then destry retain while current, plus ne year, then destry

6 Grant Related Material while the research prject is nging, plus seven years. Other ffices hlding cpies 5 Years after grant perid ends r retentin schedule as per granting agency retain while current, plus ne year, then destry Respnsibility f the Principle Investigatr UBC REQUIREMENTS: Please refer t UBC Plicy N. 85 fr cmplete detail; CLINICAL FILES (Patient Recrds): - all primary data must be recrded in clear, adequate, riginal and chrnlgical frm - in scientific departments, a recrd f the primary data, regardless f wnership, must be maintained in the labratry and cannt be remved. - riginal data fr any given study must be retained in the unit f rigin fr at least 5 years after the wrk is published r therwise presented (if the frm f the data permits this, and if assurances have nt been given that data wuld be destryed t assure annymity Recrd retentin perid Physical medical recrds f a physician must be retained fr the statutry requirement f 6 years beynd the last ffice encunter r in the case f an infant patient under the age f 19 years until thse patients reach the age f 25 years. The Cllege Quarterly recmmends that the recrds be retained fr 7 years and the CMPA recmmends that this perid be extended t 10 years beynd the date f last ffice encunter. The statutry requirement in British Clumbia fr the retentin f medical recrds is 6 years r 6 years beynd the age f majrity (i.e., age 19) fr children. Because prspective plaintiffs are given a year after filing a suit t fllw up n that actin, the Cllege recmmends anther year fr retentin f recrds, making the ttal recmmendatin 7 years. Statutes f limitatin vary frm prvince t prvince and therefre CMPA, in the physician s best interest, recmmends 10 years fr recrds retentin. Destrying/dispsing f Electrnic Medical Recrds (EMR) When destrying patient infrmatin in electrnic frm, ensure the (EMR - electrnic medical recrds/ehr - electrnic health recrd) is permanently deleted r irreversibly erased. This may require physical destructin f the electrnic strage device. As with paper recrds, prcedures are required t ensure adequate dispsing f electrnic recrds. The fllwing are sme key pints t keep in mind when cnsidering the retentin and destructin f EMRs: The required retentin perid fr medical recrds whether print r electrnic generally varies significantly depending n the jurisdictin. The CMPA recmmends that members maintain clinical recrds fr at least 10 years frm the date f the last entry, r fr at least 10 years frm the age f majrity in the case f minrs. Beynd the required retentin perid, patient infrmatin cntained in an EMR/EHR shuld nrmally nly be maintained fr as lng as is necessary fr the purpse fr which the infrmatin was cllected.

7 Once the retentin perid has been exhausted, the infrmatin in the EMR/EHR shuld generally be destryed in a manner that maintains cnfidentiality. Physicians shuld be familiar with all applicable rules r bligatins fr destrying medical recrds. Sme privacy legislatin requires physicians t keep a recrd f: The individual whse persnal health infrmatin is destryed and the time perid t which the infrmatin relates; and The methd f destructin and the persn respnsible fr supervising the destructin. Effective destructin requires the EMR/EHR be permanently deleted r irreversibly erased. When destrying the infrmatin, members must cnsider whether it is necessary t destry nt nly the riginal recrds, but als any cpies f these recrds, including back-up files. Sme privacy cmmissiners have recmmended the physical destructin f the electrnic strage device (e.g. hard drive) t ensure the permanent deletin f patient infrmatin stred n these devices. This may include physically destrying the electrnic strage device, r it may be sufficient t emply wiping sftware t delete the infrmatin cntained n the hard drive. Hwever, depending n the sphisticatin f the sftware, wiping may nt irreversibly erase every bit f data n a drive. Selling r giving away electrnic strage devices that cntain r nce cntained patient infrmatin shuld be avided. Given the technlgical expertise required t effectively destry electrnically stred infrmatin, it is preferable t engage an accredited service prvider t destry patient infrmatin maintained in EMRs. Sme privacy cmmissiners have stated that when engaging a cmmercial service prvider t dispse f patient infrmatin, physicians must enter int a written cntractual agreement with that service prvider. The agreement shuld clearly spell ut the respnsibilities f the service prvider t securely destry the health infrmatin recrds, hw the destructin will be accmplished, under what cnditins, and by whm. While nt currently a requirement in all jurisdictins, this is a prudent practice fr all members wh engage the services f a recrds dispsal cmpany.

8 Prcedures fr sending recrds t the University Archives 1. Ensure recrds have reached the end f their retentin perid and have been weeded f nn-archival material - cntact Archives if yu have electrnic recrds - in mst cases print t paper 2. Create a file list f recrds t be sent 3. Pack recrds in bx - attach file list t utside f bx (package by year if pssible) 4. Ntify Archives f amunt f material being sent 5. Send t: Attn: University Archives Irving K. Barber Learning Centre 1961 East Mall Vancuver, B.C. Canada V6T-1Z1 (604) If yu need supplies r help cntact: University Recrds Manager Alan Dyle Irving K. Barber Learning Centre 1961 East Mall Vancuver, B.C. Canada V6T-1Z1 (604) See UBC Plicy 117 Recrds Management See UBC Recrds Management Manual means the surce f instructin and reference fr creating, receiving, preparing, prcessing, string and dispsing f Recrds. See Recrds Retentin Schedule is a cntrl dcument that describes the Recrds at a series level and indicates the length f time each series shuld be retained as semi-active prir t final Dispsitin; and the final Dispsitin f each series. This dcument serves as the legal authrizatin fr the dispsal f Recrds. Created: May 2008 Updated: April 17, 2012

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