RECORD RETENTION POLICY AND PROCEDURES

Transcription

1 Category Effective Date Revised Legal 9/1/99 4/20/05 3/12/09 8/30/10 2/21/11 6/20/11 Policy & Procedures Table of Contents Chart Page 1-3 Page 1-12 Page 1-66 RECORD RETENTION POLICY AND PROCEDURES SUBJECT: SCOPE: AUTHORIZATION: DOCUMENT AND RECORD RETENTION GUIDELINES BHS, BHS Hospitals and All BHS Wholly Owned or Controlled Affiliates Tommy J. Smith, President & CEO PURPOSE: To provide minimum retention periods for documents and records maintained by Baptist Healthcare System, Inc. and its wholly owned or controlled affiliates (collectively BHS ). POLICY: All employees and agents of BHS are responsible for ensuring that all records are maintained, preserved, and destroyed in accordance with all applicable laws and regulations and this Record Retention Policy. All records generated and received by BHS are the property of BHS. No employee of BHS, by virtue of his or her position, has any personal or property right to such records even though he or she may have developed or compiled them. The unauthorized destruction, removal or use of such records is prohibited. No one may falsify or inappropriately alter information in any record or document. Information pertaining to unauthorized destruction, removal or use of BHS records or regarding falsifying or inappropriately altering information in a record or document should be reported to BHS management, either directly or through the Compliance Line ( ). The attached chart contains minimum retention periods for records to be maintained by BHS. These s apply to records maintained in any form including paper, microfilm, microfiche, Page 1

2 magnetic tape, diskette, CD, or any other electronic media. Where there is no statutory or regulatory requirement, BHS facilities may choose to change the retention period in their discretion. The retention periods are based on complying with statutory and/or regulatory requirements, meeting industry or accreditation standards and/or for litigation purposes. While it is intended that all records of BHS will be maintained in accordance with the minimum retention periods set forth in this policy, it shall not be construed to be negligence if such records are not maintained in accordance with this policy. All records listed and/or records substantially similar to those listed, must be maintained in a retrievable form for the period listed. Retrievable form may include paper copies, microfilm, microfiche, magnetic tape, diskette, CD or arrangements may be made to have the records electronically maintained. The records should be retrievable and reproducible throughout the minimum retention period. Daily BHS electronic communications, such as voice messages and s, are retained in the following manner. communications are backed up daily and saved for seven days. Sent and deleted s are saved until deleted permanently from the user s Deleted Items or Sent Items. Voice messages are maintained in individual voice mailboxes until reviewed. If messages are deleted by the reviewer, they are no longer stored and are not retrievable. Once reviewed, if not deleted by the reviewer, messages are stored for 14 days in the individual voice mailboxes. After such time, messages are automatically deleted and are not retrievable. The record retention periods will be revised and updated as needed to ensure regulatory compliance and to reflect changes in s. This and all revisions will be included and distributed as part of the BHS Legal Manual and included as a system policy on the BHS intranet. Records that have satisfied their required period of retention may be destroyed in an appropriate manner and by an appropriate method listed below. PROCEDURE: 1. Each facility and/or department will designate one or more individuals to oversee the retention of records. Such individual(s) will familiarize themselves with this policy and the attached chart of retention periods. 2. Upon determination that certain records retention period has expired, such designated person(s) may authorize the destruction of the records. 3. Records that cannot be destroyed include records with permanent retention periods and records pertaining to matters in litigation. In the event of a lawsuit or government investigation, the applicable records that are not permanent cannot be destroyed until the lawsuit or investigation has been concluded. Page 2

3 4. Records must be destroyed by an appropriate method. Appropriate methods for destroying paper include burning, shredding, pulping, and pulverizing. Methods for destroying microfilm or microfiche include recycling and pulverizing. Electronic data may be destroyed by overwriting data or reformatting disks (deleting a file is not total destruction). 5. A record of destruction must be maintained indicating the types of records destroyed, inclusive dates covered, the date of destruction, method of destruction and signature(s) of individual(s) supervising and/or witnessing the destruction. Such record of destruction shall be kept permanently and contain a statement that the records were destroyed in the normal course of business. 6. If an employee believes another employee, a contractor or other individual is impermissibly destroying records or otherwise violating this policy, he/she should contact his/her supervisor or another member of management at the facility. If an employee is uncomfortable seeking resolution in such a manner, he/she may contact the Compliance Line ( ). Approved: Tommy J. Smith Date: Page 3

4 BAPTST HEALTHCARE SYSTEM RECORD RETENTION POLICY TABLE OF CONTENTS HOSPITAL / MEDICAL RECORDS Admission/Discharge/Transfer (ADT) Logs...1 Ambulance Service Records...1 Cardiology...1 Chemical Dependency...1 Death Records...2 Department Logs / Records...2 Diagnostic Images Page 1

5 Disease Index...4 Equipment Records...4 Labs Clinical Mammography...8 Master Patient Index...9 Medical Device Reporting...9 Medical Records...9 Nuclear Medicine...10 Obstetrics and Gynecology...10 Operative Index...10 Patient Complaints...10 Peer Review Data...11 Pharmacy Page 2

6 Quality Data.. 12 Sterilization / Autoclave Records...13 Surgery Register / Log...13 HOME HEALTH Clinical Records...14 HOSPITAL / ADMINISTRATIVE RECORDS Accreditation...15 Census Reports...15 Clinical Research Records..15 Complaints...16 Contracts...16 Page 3

7 Dietary Education Electronic Communication...18 Employee Medical Records...19 Engineering Housekeeping...21 HIPAA...22 Incident Reports...23 Infection Control Laboratory...24 Lease Agreements...24 Maintenance Agreements...25 Medical Staff and Allied Health Professionals...25 Page 4

8 Medical Waste Incinerator...26 Minutes...26 Noise...26 Nursing Records OSHA Records...28 Planning...29 Permits, Licenses...29 Physician Index...29 Policies and Procedures...29 Privacy Property Records...32 Purchasing...32 Safety / Security Page 5

9 Security Patient Accounting Cash Receipts...36 Collection...36 Medicare Secondary Payer (MSP) Forms...36 Finance Accounts Payable...37 Accounts Receivable Misc Annual Report...38 Audit...38 Banking Page 6

10 Budgeting...39 Capital Property Corporate Compliance Documentation...41 Finance Health Care Provider Tax...43 Human Resources...43 Insurance Intercompany...44 Journals / Ledgers Payroll Purchasing...47 Reimbursement Tax Page 7

11 Trust Documents...50 Legal Articles of Incorporation...51 Bylaws...51 Contracts...51 Copyright / Trademark / Patent...51 Insurance Lease Agreements...52 Litigation / Claims...52 Minutes / Minute Books...52 Mortgages / Promissory Notes...52 Property Records...53 Page 8

12 Trust Documents...53 Corporate Compliance CMS / AdminaStar Letters...54 Government Letters (OIG, DHHS, OCR)...54 Compliance Internal Audits...54 Government Investigations...54 Internal Investigations...55 Compliance Hotline Calls...55 Education / Training...55 Sanction Screening of Excluded Parties...55 Page 9

13 Human Resources Accident / Injury Reports...56 Applications...56 Beneficiary Designations...56 Benefit Reports...56 Disability Plan...56 Educational Assistance Financing...56 Earnings Record...57 Employee Hazardous Exposure Record...57 Employee Medical Records...57 Employee Requisition Files...57 Flexible Spending Accounts...57 Hazard Communication Record...58 Page 10

14 Health Insurance Claims...56 Incentive Plan Records...58 Job Announcements...58 Layoff Records...58 Life Insurance Records...58 Paid Time Off Records...59 Pay Scales...59 Pension / 401(k) Retirement Plan Vesting Files...59 Personnel Action Request Forms...59 Personnel Files...59 Profit Sharing Records...60 Radiation Exposure Records...60 Relocation Records...60 Page 11

15 Salary Surveys...60 Tax Payment Records...60 Time Cards...60 Verification of Employment Eligibility...60 W-2 Forms...61 PHYSICIAN OFFICE MEDICAL RECORDS MISCELLANEOUS Grants...64 KENTUCKY STATUTE OF LIMITATIONS Page 12

16 HOSPITAL / MEDICAL RECORDS TYPE NOTES RETAIN AUTHORITY COMMENTS Admission/Discharge/ Transfer (ADT) Logs 5 Yrs from date of transfer 42 CFR EMTALA requires all records, including logs of transfers, be retained for 5 years. Ambulance Service Records Run Report Forms - From Date Or Age Of Majority Personnel File Of Driver And Attendant - From Last Date Of Employment 5 Yrs 902 KAR 14:080 5 Yrs 902 KAR 14:080 Cardiology / Cath Lab See Diagnostics Chemical Dependency From Last Discharge After Age Of Majority 5 Yrs 5 Yrs 902 KAR 20:160 Sect. 3 (requires 3 yrs after the age of majority) Page 1

17 TYPE NOTES RETAIN AUTHORITY COMMENTS Death Records (Adults & Minors) DOD, Name/Address Of Who Body Is Released To, Date Of Removal 5 Yrs KRS Department Logs / Records (except OB, ER, OR see special rules) Examples: Occupational Therapy Pulmonary Therapy Physical Therapy Rehab Sleep Disorders Lab Speech Pathology Adults-5 Yrs Minors-age of majority plus 5 Yrs 42 CFR governs clinics and rehab agencies as providers of outpatient physical therapy and speech-language pathology services Page 2

18 TYPE NOTES RETAIN AUTHORITY COMMENTS Diagnostic Images Raw data Adults-5 Yrs Minors-age of majority plus 5 Yrs Examples Nuclear Medicine: Patient Procedure Log Radiation Film Monitoring Records Radioactive Materials Licenses, Logs Radioisotope Records Regulatory Inspection Reports Reports 42 CFR (5 yrs) AHIMA (5 yrs) Page 3

19 TYPE NOTES RETAIN AUTHORITY COMMENTS Diagnostic Images (Continued) Examples Other: Cine Film, CD s EEG EKG Electrocardiogram Electroencephalogra m Holter Monitor Log Tracings Vascular Study Video Tapes X-rays Disease Index 10 Yrs AHIMA Electronically maintained by IS Equipment Records Life of Equipment Plus 2 Yrs Page 4

20 TYPE NOTES RETAIN AUTHORITY COMMENTS Labs - Clinical (CLIA Regulations) Proficiency Testing Test Records Test Reports Quality Control Test 2 Yrs From Report Date 2 Yrs 2 Yrs 2 Yrs 42 CFR All Laboratories must comply with CLIA regulations at a 42 CFR CFR CFR Minimum. CAP has deemed status from CLIA, thus CAP certified laboratories must follow CAP s for record retention. Immunohematology Test Records Test Reports Quality Control Records Transfusion Records Discontinued Policies & Procedures 5 Yrs 5 Yrs 5 Yrs 5 Yrs 2 Yrs 42 CFR CFR CFR CFR CFR Note: State Laws supercede CAP regulations. Pathology Test Reports Discontinued Policies & Procedures 10 Yrs 2 Yrs 42 CFR CFR Page 5

21 TYPE NOTES RETAIN AUTHORITY COMMENTS Labs Clinical (CAP) Discontinued Policies & Procedures Specimen Requisitions Test Results & Reports Instrument Printouts Accession Records Quality Control Records Proficiency Testing Records Quality Improvement Records 2 Yrs 2 Yrs 2 Yrs 2 Yrs 2 Yrs 2 Yrs 2 Yrs 2 Yrs Edition CAP General Checklist Questions All Laboratories must comply with CLIA regulations at a minimum. CAP has deemed status from CLIA, thus CAP certified laboratories must follow CAP s for record retention. Note: State Laws supercede CAP regulations. Maintenance Records Life of Analyzer Serum and Body Fluid Specimens 24 hours Page 6

22 TYPE NOTES RETAIN AUTHORITY COMMENTS Labs Clinical (CAP) (Continued) Blood Films, Permanently Stained Body Fluid Slides and Microbiology Slides 7 Days Pathology Accession Log Records Wet Tissue Paraffin Blocks Slides Reports Breast Implants Cytology Reports Slides Fine Needle Aspiration Slides 2 Yrs 2 Weeks 5 Yrs 10 Yrs 10 Yrs 2 Yrs from date of removal 10 Yrs 5 Yrs 10 Yrs Edition CAP Anatomic Pathology Checklist Question Edition CAP Cytology Checklist Question 08.A0690 Page 7

23 TYPE NOTES RETAIN AUTHORITY COMMENTS Labs Clinical (CAP) (Continued) Immunohematology / Transfusion Services Permanently Deferred Donors Reports Donor & Recipient Records Records of Employee Signatures Initials Identification Codes Donor & Recipient Specimens Indefinitely 5 Yrs 5 Yrs 5 Yrs 5 Yrs 5 Yrs 7 days Posttransfusion or at least 10 days post-crossmatch Edition CAP Transfusion Medicine Checklist (See also 21 CFR (d) and 42 CFR through ) Mammography Records Of Screenings -From Date Of Service 10 Yrs 21 CFR (c)(4)(i) KRS ACR Page 8

24 TYPE NOTES RETAIN AUTHORITY COMMENTS Master Patient Index Dates Of Visits, Names Of Physicians, Record Of Diagnosis Permanent AHIMA KRS (5 yrs) Electronically Maintained by IS Medical Device Reporting Complaints And MDR Reports 2 Yrs after the event 21 CFR For retention requirements for Breast Implants removed, see Labs - Clinical Medical Records Original Or Legally Reproducible Form Adults - 10 Yrs Minors age of majority plus 5 Yrs 902 KAR 20:016 Sect. 3 (11) 2 (5 Yrs, majority plus 3 Yrs) False Claims Act 31 USC 3731 AHIMA / AHA (10 Yrs) Original written portions of medical record that are scanned into electronic medical record Minimum of 3 months Risk Management or Legal Departments may request records to be retained longer. Page 9

25 TYPE NOTES RETAIN AUTHORITY COMMENTS Nuclear Medicine See Diagnostices Obstetrics And Gynecology Examples: Fetal Heart Monitor Birth Records - Info For Certificates Patient Treatment Records / Charts Register / Log Ultrasounds On Video Adults 10 Yrs Minors age of majority plus 5 Yrs AHIMA (10 Yrs) KRS (5 Yrs) AHIMA (permanent) Policy And Procedure Manuals 23 Yrs Operative Index 10 Yrs AHIMA Electronically Maintained by IS Patient Complaints (excluding those relating to HIPAA privacy or security) 2 Yrs Page 10

26 TYPE NOTES RETAIN AUTHORITY COMMENTS Peer Review Data 4 Yrs Pharmacy Record Of Prescribed Drugs Dispensed (All Information) Records Of Controlled Substances Received And Disposed 2 Yrs KRS Yrs KRS 218A CFR Computerized Record Of Prescription And Refills Patient Records From Date Of Last Entry 5 Yrs 201 KAR 2: CFR (2 yrs) 180 Days 201 KAR 2:210 Page 11

27 TYPE NOTES RETAIN AUTHORITY COMMENTS Pharmacy (Continued) Parenteral Pharmaceutical Compounding - Patient Profile From Last Dispension Paper copy - 2 Yrs, Computer Data 5 Yrs 201 KAR 2: KAR 2:076 MAR As Part Of Medical Record Sale Of Hypodermic Needles - Name, Address, Quantity, Date Of Sale, Planned Use 5 Yrs From Discharge 2 Yrs KRS Retention should be the same as the medical record, kept in the medical record Quality Data 4 Yrs Page 12

28 TYPE NOTES RETAIN AUTHORITY COMMENTS Sterilization / Autoclave Records 5 Yrs AAMI (The Association for the Advancement of Medical Instrumentation) Surgery Register/Log 5 Yrs Page 13

29 HOME HEALTH TYPE NOTES RETAIN AUTHORITY COMMENTS Clinical Records Adult -10 Yrs Minor age of majority plus 3 Yrs 42 CFR (a) False Claims Act 31 USC 3731 Page 14

30 HOSPITAL / ADMINISTRATIVE RECORDS TYPE NOTES RETAIN AUTHORITY COMMENTS Accreditation Permanent JCAHO & State Licensure Surveys Permanent Census Reports Hospital Daily Census Report/Summary 3 years Clinical Research Records Includes all IRB records, for example, minutes of all IRB meetings, research, proposals reviewed by the IRB, consent forms approved by the IRB, correspondence between the IRB and investigators, and records of continuing review activities. 3 years after completion of the research or longer if required by sponsor 21 CFR FDA regulations require all IRB related research records to be retained for at least 3 years after completion of the research. Page 15

31 TYPE NOTES RETAIN AUTHORITY COMMENTS Complaints (HIPAA Privacy and Security) Documentation of verbal or written complaints regarding compliance with privacy and/or security regulations 6 years from the date of creation 42 CFR CFR Documentation of complaints, investigations, and resolutions should be maintained for retention period by BHS Privacy or Security Officers. Contracts 10 Yrs Following Termination Date Dietary Food Cost Includes: Budgets Expense reports 5 Yrs Inspection Reports 3 Yrs Inventory 2 Yrs Page 16

32 TYPE NOTES RETAIN AUTHORITY COMMENTS Dietary (Continued) Meal Counts 2 Yrs Menus 2 Yrs 902 KAR 20:016 (30 days) Purchase Orders 3 Yrs Sales Receipts 5 Yrs Kept for Tax purposes Staff Schedules 2 Yrs Education BCLS, ACLS, PALS Records 5 Yrs CE Program Summary Forms & Attendance 5 Yrs Retention periods based on requirements of JCAHO and survey process. CE Course Outlines 5 Yrs Page 17

33 TYPE NOTES RETAIN AUTHORITY COMMENTS Education (Continued) New Hire Orientation 5 Yrs Nursing CE And Inservice Records 5 Yrs KBN Regulations (24 CFR yrs) CPR Certification 5 Yrs Privacy and Security (HIPAA) 6 Yrs 42 CFR CFR Includes computer based training and department in-service records Electronic Communications s 7 days data files are backed up daily and saved for 7 days. Voice messages 14 days Messages are held until reviewed. After reviewed, if not deleted, messages are stored for 14 days in individual voice mailboxes, after which they are automatically deleted and no longer retrievable. Page 18

34 TYPE NOTES RETAIN AUTHORITY COMMENTS Employee Medical Records Employee Medical Records 30 Yrs 29 CFR Engineering Construction Projects 15 Yrs after completion Blueprints / Drawings Permanent Equipment Records (Operating Manual, Inspection, Maintenance) Life Of Equipment Plus 2 Yrs ETO And Steam Log Book Fire Drill And Alarm Reports, Training Records 5 Yrs 3 Yrs Page 19

35 TYPE NOTES RETAIN AUTHORITY COMMENTS Engineering (Continued) Inspection Of Grounds 3 Yrs Inspections Electrical Distribution, Elevator, Incinerator, Grounds, Buildings 3 Yrs Licenses / Permits Licenses / Permits - Building Preventive Maintenance Records (Non-Clinical Equipment) Permanent Warranty Period plus 1 Yr or 3 Yrs (whichever is longest) Page 20

36 TYPE NOTES RETAIN AUTHORITY COMMENTS Engineering (Continued) Service Contracts Service Contracts Statute of Limitations in Kentucky Special Waste Hauling Permanent Housekeeping Staff Schedules 2 Yrs Room Records 3 Yrs Procedures / Polices 5 Yrs Page 21

37 TYPE NOTES RETAIN AUTHORITY COMMENTS HIPAA (see also Complaints, Education Records, Privacy, and Security) Policies and Procedures 42 CFR CFR Yrs from creation date or the last effective date, whichever is later Primary location on BHS Intranet; may also be located at BHS Help Desk and/or BHS facilities. Required Communication 6 Yrs from creation date or the last effective date, whichever is later 42 CFR CFR Communication required by HIPAA includes, but is not limited to, notices of privacy practices, communication to individuals filing complaints and requesting amendments to records, and internal communication. Documentation of any action, activity or designation required by Privacy or Security Rules 6 Yrs from creation date or the last effective date, whichever is later 42 CFR CFR Examples include complaints, investigations, audits, sanctions, education records, authorizations to release records, and written acknowledgments of privacy notices Page 22

38 TYPE NOTES RETAIN AUTHORITY COMMENTS Incident Reports Visitor Incidents Patient Incidents (Minor & Adult) 2 Yrs 2 Yrs Infection Control Training Records training materials, attendance record (Except for Bloodborne Pathogen Training Records see OSHA Records) Communicable Disease Reports 1 Yr 2 Yrs Multiple Drug Resistant Organisms Data (MDRO Data) 10 Yrs from date of infection for both adults and minors Page 23

39 TYPE NOTES RETAIN AUTHORITY COMMENTS Infection Control (Continued) Infection Control Surveillance or Other Infection Control Data (Except for MDRO Data) 4 Yrs Kept By Infection Control Nurse Nosocomial Worksheet 3 Yrs Laboratory Staffing Schedules Minutes 2 Yrs 3 Yrs Lease Agreements 10 Yrs Following Termination Date Page 24

40 TYPE NOTES RETAIN AUTHORITY COMMENTS Maintenance Agreements 10 Yrs Following Termination Date Medical Staff and Allied Health Professionals Minutes Bylaws Permanent Permanent Note: Regulations re: credentials, minutes, etc., require they be made part of permanent record of hospital administration. Credentialing Files Permanent Inactive Medical Staff Files Peer Review Committee Minutes Physician Contracts Permanent Permanent 10 Yrs Following Termination Page 25

41 TYPE NOTES RETAIN AUTHORITY COMMENTS Medical Waste Incinerator records and manifest 3 Yrs 401 KAR 32:040 records of CEMS, steam flow, temperature data 2 Yrs 401 KAR 59:023 names and dates of persons required to review operating manual and documentation 2 Yrs from date of review 401 KAR 61:013 Minutes Department Minutes 3 Yrs Noise monitoring records that are part of audiometric record duration of employment 29 CFR monitoring records 2 Yrs 29 CFR Page 26

42 TYPE NOTES RETAIN AUTHORITY COMMENTS Nursing Records Staff Schedules 5 Yrs Committee Minutes 3 Yrs Policies / Procedures 5 Yrs QA Studies / Reports 3 Yrs Orientation Records / Skills Checklist Term Of Employment plus 3 Yrs Logbooks 5 Yrs Crash Cart Check Log 3 Yrs Page 27

43 TYPE NOTES RETAIN AUTHORITY COMMENTS Nursing Records (Continued) Infection Control Surveillance or Other Infection Control Data (Except for MDRO Data) 4 Yrs Kept By Infection Control Nurse OSHA Records log of occupational injuries/illnesses 5 Yrs 29 CFR and Recordable Occupational Injuries and Illness Employee records of exposure, medical records of examination, analysis of records 30 Yrs 29 CFR CFR (formaldehyde) Bloodborne Pathogen Training Records 3 Yrs 29 CFR Page 28

44 TYPE NOTES RETAIN AUTHORITY COMMENTS Planning CON Application And CHR Approvals Permanent Permits, Licenses Permanent Physician Index Record of Procedures Done by Physicians 10 Yrs AHIMA Policies and Procedures Electronic and/or Paper Policies 23 Yrs Applies to all policies for system, hospital, department and affiliated entities. Policies maintained on the Intranet are achieved electronically. Page 29

45 TYPE NOTES RETAIN AUTHORITY COMMENTS Privacy (of medical records and other protected health information -- HIPAA) Complaints 42 CFR Yrs from the date of creation or last effective date, whichever is later Documentation of complaints, resulting investigations and dispositions should be maintained by BHS Privacy Officer. Education/Training 6 Yrs from the date of creation or last effective date, whichever is later 42 CFR Includes computer based training and department in-service records. Policies and Procedures 6 Yrs from the date of creation or last effective date, whichever is later 42 CFR Primary location is BHS Intranet. Should be changed and updated as necessary and appropriate to comply with changes in laws. Updates should be communicated via BHS Intranet and, as appropriate, incorporated in education of workforce Page 30

46 TYPE NOTES RETAIN AUTHORITY COMMENTS Privacy (HIPAA) (Continued) Sanctions 6 Yrs from the date of creation or last effective date, whichever is later 42 CFR Documentation of sanctions applied to members of workforce (employees, volunteers) and medical staff should be maintained by appropriate department of BHS facility (e.g. Human Resources, Medical Staff Office) and BHS Privacy Officer. Documentation of any action, activity or assessment required by the Privacy Rule 6 Yrs from the date of creation or last effective date, whichever is later 42 CFR Examples include complaints, investigations, audits, authorizations to release records, changes in privacy notices, and written acknowledgments of privacy notices. Should be maintained by appropriate department of BHS facility and BHS Privacy Officer. Page 31

47 TYPE NOTES RETAIN AUTHORITY COMMENTS Property Records Deeds Title Insurance Permanent Permanent Environmental Survey Permanent Purchasing Capital Budget Purchasing Orders Delivery Tickets / Packing Slips 3 Yrs 1 Yr After Purchase Orders 7 Yrs Requisitions 1 Yr Signatory Authority For Purchases Permanent Page 32

48 TYPE NOTES RETAIN AUTHORITY COMMENTS Safety / Security Duty Logs 3 Yrs Emergency Action / Preparedness Plans Incident Reports Examples: Theft reports Visitor falls Incidents involving security intervention Policies and Procedures Safety Committee Reports / Minutes Security Management Plan 5 Yrs 2 Yrs 5 Yrs 3 Yrs 5 Yrs Page 33

49 TYPE NOTES RETAIN AUTHORITY COMMENTS Safety / Security (Continued) Tour Report (Ground Inspections) 3 Yrs Security (of electronic medical records and other protected health information -- HIPAA) Policies and Procedures 6 Yrs. (from the date of creation or when last in effect, whichever is later) 42 CFR Primary location on BHS Intranet. May also be located in written form at the BHS Help Desk and at individual BHS facilities. Should be reviewed periodically and updated when needed in response to environmental or operational changes affecting the security of electronic protected health information. Updates and changes will be communicated via the BHS Intranet and, as appropriate, incorporated in workforce education. Page 34

50 TYPE NOTES RETAIN AUTHORITY COMMENTS Security (of electronic medical records and other protected health information -- HIPAA) (Continued) Documentation of any action, activity or assessment required by the Security Rule 6 Yrs. (from the date of creation or when last in effect, whichever is later) 42 CFR Should be maintained by the BHS Security Officer. In addition, copies may also be kept at particular BHS facility (e.g. sanction of an employee kept in HR file, investigation of a complaint kept by facility privacy officer). Page 35

51 PATIENT ACCOUNTING TYPE NOTES RETAIN AUTHORITY COMMENTS Cash Receipts Includes Medicare Remittances 7 Yrs Collection Collection Records Tax Return Filing Date + 10 Yrs 26 CFR (E)-1 Records related to the management and collection of bad debts Bad Debt Reports Tax Return Filing Date + 10 Yrs 26 CFR (E)-1 Reports detailing bad debts write-offs Medicare Secondary Payer (MSP) Forms Includes MSP Information 10 Yrs 42 CFR (f) / CMS Intranet Manual Chapter 3 Section Page 36

52 FINANCE TYPE NOTES RETAIN AUTHORITY COMMENTS Accounts Payable Check Register CY + 6 Yrs 26 CFR (E)-1 Invoices / Vouchers Examples: Credit Card Statements Donations Expense reports Petty Cash Reimbursement Request Insurance Payments (Unemployment, Worker s Comp) CY + 6 Yrs 26 CFR (E)-1 Accounts Receivable Misc. (does not include patient accounting) Cash Receipts CY + 6 Yrs 26 CFR (E)-1 Credit Advices CY + 6 Yrs 26 CFR (E)-1 Records documenting payments which result in credit due Invoices CY + 6 Yrs 26 CFR (E)-1 Page 37

53 TYPE NOTES RETAIN AUTHORITY COMMENTS Accounts Receivable Misc. (Continued) Reconciliations CY + 6 Yrs 26 CFR (E)-1 Reports and workpapers used to reconcile account receivable accounts Sales Receipts CY + 6 Yrs 26 CFR (E)-1 Retain daily summary logs (not daily receipt tapes) Annual Report CY + 10 Yrs 26 CFR (E)-1 Retained by BHS Audit External Reports CY + 10 Yrs 26 CFR (E)-1 Retained by BHS Internal Reports CY + 6 Yrs Workpapers CY + 3 Yrs Retained by BHS Records supporting audit reports, prepared as part of the audit process Banking Bank Deposits CY + 6 Yrs 26 CFR (E)-1 Bank Reconciliations CY + 6 Yrs 26 CFR (E)-1 Bank Statements CY + 6 Yrs 26 CFR (E)-1 Page 38

54 TYPE NOTES RETAIN AUTHORITY COMMENTS Banking (Continued) Check Registers CY + 6 Yrs 26 CFR (E)-1 Check Copies / Stubs CY + 6 Yrs Checks Paid / Cleared CY + 6 Yrs 26 CFR (E)-1 Transaction Notices CY + 6 Yrs 26 CFR (E)-1 Wire Transfers CY + 6 Yrs 26 CFR (E)-1 Budgeting Budgets Approved CY + 1 Yr Retained by BHS Budget & Variance Reports CY + 1Yr Budget versus actual with variance Workpapers CY + 1 Yr Capital Property Acquisitions CY + 6 Yrs 26 CFR 1.167(A)-11,12 26 CFR (E)-1 Records documenting the purchase of property and equipment Page 39

55 TYPE NOTES RETAIN AUTHORITY COMMENTS Capital Property (Continued) Capital Asset Records CY + 6 Yrs 26 CFR 1.167(A)-11,12 26 CFR (E)-1 Records documenting the purchase and sale of property and equipment, including depreciation, improvements, tax credit, and depletion Capital Expenditure Receipts and Reports CY + 6 Yrs 26 CFR 1.167(A)-11,12 26 CFR (E)-1 Construction Accounting Reports and Workpapers CY + 6 Yrs 26 CFR 1.167(A)-11,12 26 CFR (E)-1 Construction in progress reports, cost analysis reports, etc. Depreciation Schedules and Workpapers CY + 6 Yrs 26 CFR 1.167(A)-11,12 26 CFR (E)-1 Reports and workpapers detailing deprecation, gain/loss and sales of fixed assets Fixed Asset Schedules CY + 6 Yrs 26 CFR 1.167(A)-11,12 26 CFR (E)-1 Material Transfer Files CY + 6 Yrs 26 CFR 1.167(A)-11,12 26 CFR (E)-1 Records documenting physical transfer of material and property from one location to another and the related transfer of accounting charges Page 40

56 TYPE NOTES RETAIN AUTHORITY COMMENTS Capital Property (Continued) Property Inventory CY + 6 Yrs 26 CFR 1.167(A)-11,12 26 CFR (E)-1 Property Sold CY + 6 Yrs 26 CFR 1.167(A)-11,12 26 CFR (E)-1 Records documenting the type, model and location of property and equipment Corporate Compliance Documentation Permanent Finance Bonds / Debentures and Workpapers Credit Agency Reports Year of cash defeasance + 7 Yrs CY + 2 Yrs 26 CFR 1.167(A)-11,12 26 CFR (E)-1 Records related to corporate debentures and corporate bonds, as well as workpapers related to analysis of corporate debt Financial Statements Monthly / Quarterly CY + 2 Yrs Retained by BHS Page 41

57 TYPE NOTES RETAIN AUTHORITY COMMENTS Finance (Continued) Investments Examples: Investment reports Real estate purchase Purchase of Securities Annual statements CY + 7 Yrs 26 CFR 1.167(A)-11,12 26 CFR (E)-1 Leases 10 Yrs after termination Letters of Credit 6 Yrs after termination 26 CFR 1.167(A)-11,12 26 CFR (E)-1 Retained by BHS Loan Applications, Agreements 6 Yrs after termination 26 CFR 1.167(A)-11,12 26 CFR (E)-1 Mortgage Records 10 Yrs after termination Notes 6 Yrs after termination 26 CFR (E)-1 Page 42

58 TYPE NOTES RETAIN AUTHORITY COMMENTS Finance (Continued) Planning (Financial) Examples: Forecast Projections Strategic development CY + 6 Yrs Health Care Provider Tax Records, Receipts, Invoices 6 Yrs KRS Human Resources Flexible Spending Accounts CY + 6 Yrs 29 CFR USC 113 Journal entry support documents. Paid Time Off Records CY + 6 Yrs 29 CFR USC 113 Journal entry support documents. Insurance Policies And Related Documents Example: Trust Reconciliations CY + 6 Yrs or Expiration 806 KAR 2:070 Page 43

59 TYPE NOTES RETAIN AUTHORITY COMMENTS Insurance (Continued) Policies And 3 rd Party Payor Contracts Example: Managed Care 10 Yrs Following Termination Date Intercompany Invoices CY + 6 Yrs 26 CFR (E)-1 Invoices detailing intercompany account transactions Journals / Ledgers Accounts Payable Monthly Distribution CY + 6 Yrs 26 CFR (E)-1 Accounts Receivables Ledgers CY + 6 Yrs 26 CFR (E)-1 Cash Journals CY + 6 Yrs 26 CFR (E)-1 Chart of Accounts CY + 6 Yrs 26 CFR (E)-1 Listing of account names and codes used in the accounting system General Ledger / Subsidiary Ledgers CY + 6 Yrs 26 CFR (E)-1 Consolidated, cumulative general ledger or subsidiary ledgers published at year end (Detailed General Ledger Kept Electronically or on Microfiche) Page 44

60 TYPE NOTES RETAIN AUTHORITY COMMENTS Journals / Ledgers (Continued) Monthly Close Package Journal Entries and Adjustments Examples: Cash receipts Intercompany Corrections Purchase or Sale of Entities / Affiliates / Joint Venture CY + 6 Yrs 26 CFR (E)-1 Accounting workpapers processed at the closing of the monthly general ledger CY + 6 Yrs 26 CFR (E)-1 Records detailing transactions and corrections in the general ledger Tax Return Filing Date + 15 Yrs Trial Balances CY + 6 Yrs Payroll Checks Paid / Cleared CY + 6 Yrs 26 CFR (E)-1 Checks issued for payroll that have been cashed and returned by the bank Earnings Records CY + 6 Yrs 29 CFR Records summarizing earning of individual employees Page 45

61 TYPE NOTES RETAIN AUTHORITY COMMENTS Payroll (Continued) Garnishment Accounting CY + 6 Yrs 26 CFR (E)-1 Records related to the withholding and payment to third parties of amounts garnished from employee wages Garnishment Orders Active Orders + 1 Yr Payroll Records CY + 6 Yrs 26 CFR CFR (E)-1 Records documenting payments for payroll over time including dates, employee names, withholding amounts and purpose, final check amounts and other related information. Payroll Registers CY + 6 Yrs 26 CFR (E)-1 Records detailing payroll amounts, deductions, and taxes for each employee Payroll Reports and Workpapers Payroll Reconciliations CY + 6 Yrs 26 CFR CFR (E)-1 CY + 6 Yrs 26 CFR CFR (E)-1 Page 46

62 TYPE NOTES RETAIN AUTHORITY COMMENTS Payroll Time Cards 2 Yrs KRS (Continued) W-2 CY + 6 Yrs 26 CFR (E)-1 Purchasing Bids Accepted CY + 6 Yrs Catalogs / Price List Until superseded Purchase Orders CY + 6 Yrs 26 CFR (E)-1 Receiving documentation CY + 6 Yrs 26 CFR (E)-1 Reimbursement Correspondence Examples: OIG Request With HHS With Fiscal Intermediaries CY + 15 Yrs after Medicare Appeals Process Page 47

63 TYPE NOTES RETAIN AUTHORITY COMMENTS Reimbursement (Continued) Cost reports and workpapers, filed and audited CY + 15 Yrs after Medicare Appeals Process 42 CFR CFR Cost report appeals and workpapers, filed and audited CY + 15 Yrs after Medicare Appeals Process 42 CFR CFR Cost report support papers CY + 15 Yrs after Medicare Appeals Process 42 CFR CFR Supporting documents used to construct the cost report Page 48

64 TYPE NOTES RETAIN AUTHORITY COMMENTS Tax Federal Tax returns, reports, workpapers and correspondence Examples: Income tax Excise tax Employment tax IRS Audit reports Protest Appeals Claims for Refunds Tax return filing date + 15 Yrs 26 CFR (E)-1 State and Local tax returns, reports, workpapers and correspondence Examples: Income tax Employment tax IRS Audit reports Protest Appeals Claims for Refunds Tax return filing date + 15 Yrs KRS (requires 5 Yrs after filing return) Page 49

65 TYPE NOTES RETAIN AUTHORITY COMMENTS Tax (Continued) Form 1099 CY + 6 Yrs 26 CFR (E)-1 Form 940 / 941 CY + 6 Yrs 26 CFR (E)-1 Health Care Provider Tax Tax return filing date + 6 Yrs KRS Records, receipts and invoices Research Files CY + 6 Yrs 26 CFR (E)-1 Research files for tax issues Tax Compliance Files Tax return filing date + 10 Yrs 26 CFR (E)-1 Trust Documents (Health, Workers Comp, Malpractice) Examples: Policies Workpapers Statements CY + 10 Yrs Page 50

66 LEGAL TYPE NOTES RETAIN AUTHORITY COMMENTS Articles of Incorporation Permanent Includes Affiliated Corporations and Joint Ventures Bylaws Permanent Includes Affiliated Corporations and Joint Ventures Contracts 10 Yrs Following Termination Date Copyright / Trademark / Patent Records of rights conveyed 6 Yrs 35 USC 286 Insurance see also Trust Documents Policies And Related Documents 5 Yrs After Termination or Expiration 806 KAR 2:070 Record Of Insurance 5 Yrs Page 51

67 TYPE NOTES RETAIN AUTHORITY COMMENTS Insurance see also Trust Documents (continued) Claims Made Policies Indefinitely Policies And 3 rd Party Payor Contracts Permanent Lease Agreements 10 Yrs Following Termination Date Litigation / Claims Medical Malpractice 10 Yrs After Final Disposition Statute of Limitations Minutes / Minute Book Board of Directors / Shareholders Permanent Includes Affiliated Corporations and Joint Ventures May be put in Storage 2 years after dissolution of the Corporation. Mortgages / Promissory Notes After satisfaction 10 Yrs Page 52

68 TYPE NOTES RETAIN AUTHORITY COMMENTS Property Records Deeds Title Insurance Environmental Survey Permanent Permanent Permanent Trust Documents (Health, Workers Comp, Malpractice) Examples: Policies Workpapers Statements CY + 10 Yrs Page 53

69 CORPORATE COMPLIANCE TYPE NOTES RETAIN AUTHORITY COMMENTS CMS /AdminaStar Letters Government Letters (OIG, DHHS, OCR) Compliance - Internal Audits Government Investigations Includes Additional Documentation Requests and Response to CMS Includes formal request related to compliance and HIPAA also includes response to request Compliance Audit Results and Workpapers Correspondence from Government, investigation workpapers and response 7 Yrs 7 Yrs 7 Yrs 7 Yrs Page 54

70 TYPE NOTES RETAIN AUTHORITY COMMENTS Internal Investigations Compliance Hotline Calls Education / Training Sanction Screening of Excluded Parties Reports and Workpapers Documentation of call and action taken Documentation of Completion Screening documentation and resolution of matches 7 Yrs 7 Yrs 7 Yrs 7 Yrs Page 55

71 HUMAN RESOURCES TYPE NOTES RETAIN AUTHORITY COMMENTS Accident / Injury Reports Applications Job-related accidents and injuries Rejected, individuals not hired 5 Yrs 29 CFR Yr 29 CFR Beneficiary Designations 6 Yrs from revision or payout 29 CFR USC 1027 Benefit Reports Disability Plan Govt required reports relating to benefits and benefit plans Employee eligibility and benefits under the plan 5 Yrs 29 CFR 30.8(E) 6 Yrs 29 CFR USC 1027 Educational Assistance Financing From last action date 6 Yrs 29 CFR USC 113 Page 56

72 TYPE NOTES RETAIN AUTHORITY COMMENTS Earnings Record Employee Hazardous Exposure Records Employee Medical Records Employee Medical Records Employee Requisition Files Flexible Spending Accounts Records summarizing earnings of individual employees Related to hazardous exposure Not related to hazardous exposure Related to requisition of new employees 7 yrs 29 CFR Yrs 29 CFR CFR Yrs 29 CFR CFR Yrs 29 CFR Yrs 29 CFR Yrs 29 CFR USC 113 Page 57

73 TYPE NOTES RETAIN AUTHORITY COMMENTS Hazard Communication Records Health Insurance Claims Incentive Plan Records Job Announcements Layoff Records Communication of information about hazardous substances or situations Benefits received, claims, summary reports, correspondence, etc. Benefits received, summary reports, etc. Notice of job openings communicated in the media or other means Related to corporate labor force reductions 30 Yrs 29 CFR CFR Yrs 29 CFR USC Yrs 29 CFR USC Yr 29 CFR Yrs 29 CFR CFR CFR Page 58

74 TYPE NOTES RETAIN AUTHORITY COMMENTS Life Insurance Records (Group) Paid Time Off Records Pay Scales Pension / 401(k) Retirement Plan Vesting Files Personnel Action Request Forms Benefits received claims, summary reports, correspondence, etc. Time accrued and used Charts used to determine salary for job classifications Employees vested under the plan and eligible for payments Used by HR to create/change employee information 6 Yrs 29 CFR USC Yrs 29 CFR USC Yrs 29 CFR Yrs 29 USC Yrs 29 CFR CFR CFR Personnel Files Personnel actions, evaluations, salary, etc. 6 Yrs after termination 29 CFR CFR CFR Page 59

75 TYPE NOTES RETAIN AUTHORITY COMMENTS Profit Sharing Records Radiation Exposure Records Benefits received, correspondence, summary reports, etc. 6 Yrs 29 CFR USC Yrs 29 CFR CFR Relocation Records From last action date 6 Yrs 29 CFR USC 113 Salary Surveys 6 Yrs 29 CFR Tax Payment Records Kentucky 7 Yrs KRS Time Cards 2 Yrs KRS Verification of Employment Eligibility INS Form I-9 3 Yrs 8 CFR 274A.2 Page 60

76 TYPE NOTES RETAIN AUTHORITY COMMENTS W-2 Forms 7 Yrs 26 CFR (E)-1 (requires 6 Yrs after return filed) Page 61

77 PHYSICIAN MEDICAL OFFICE RECORDS Baptist physician practices will comply with this policy and the retention periods specified for all documents and records in the policy except as noted below. See also BHS Policy for Document and Record Retention Guidelines for Baptist Physician Medical Offices. TYPE NOTES RETAIN AUTHORITY COMMENTS Medical Records Adults Original or Legally Reproducible Form 11 Years 906 KAR 1:070, (5 years after a patient s death or discharge) Civil False Claims Act --31 U.S.C (in no event no more than 10 years after the violation) Medicaid Program Physician Manual KAR 3:005 (5 years) Kentucky s Statute of Limitations for Medical Malpractice Cases (KRS (no later than 5 years after event occurred) Page 62

78 TYPE NOTES RETAIN AUTHORITY COMMENTS Medical Records Minors Original or Legally Reproducible Form Age of majority (18) plus 11 years 906 KAR 1:070, 902 KAR 20:260 Medical Records Incompetents Original or Legally Reproducible Form Indefinitely or 11 years after death The statute of limitations never begins to run as to patients who are mentally incompetent. Medical Records Deceased patients Original or Legally Reproducible Form 11 years after death Medical Records Immunization Records Original or Legally Reproducible Form Retain for same periods as other Medical Records Medical Records Original written portions of medical record that are scanned into electronic medical record Minimum of 3 months Risk Management or Legal Departments may request records to be retained longer. Appointment Books 3 Years Page 63

79 MISCELLANEOUS TYPE NOTES RETAIN AUTHORITY COMMENTS Grants records kept pursuant to 45 CFR Part 74 - from date of final expenditure report or quarterly/annual report 3 Yrs or til resolution of any actions 45 CFR and 42 CFR Federal for community health service projects National Heart, Lung, and Blood Institute National Cancer Institute same 42 CFR 51c.112 same 42 CFR 52a.8 same 42 CFR 52b.6 Dept. Local Government re: capital projects 5 Yrs from completion KRS Page 64

80 KENTUCKY STATUTE OF LIMITATIONS Note: Age of Majority in Kentucky is 18 Actions Not Provided For In Statutes 10 Yrs KRS Action Upon Bill Of Exchange 5 Yrs KRS Breach Of Contract For Sale 4 Yrs KRS Default Of Lease Contract 4 Yrs KRS 355.2A-506 Fraud/Mistake From Discovery From Date Of Occurrence 5 Yrs 10 Yrs KRS KRS Libel / Slander 1 Yr KRS Malpractice / Personal Injury From Discovery From Date Of Occurrence 1 Yr 5 Yrs KRS KRS Oral Contract 5 Yrs KRS Trespass Of Real Or Personal Property 5 Yrs KRS Page 65

81 Wrongful Death / Injury To Person Due To Construction Of Improvement Of Real Property 7 Yrs KRS Wage Discrimination Because Of Sex Discrimination - As Filed With Commission On Human Rights Upon Final Order May File With Circuit Court 6 mos from occurrence 180 days from occurrence 30 days KRS KRS KRS 13B.140 Page 66