RECORDS MANAGEMENT POLICY PURPOSE The purpose of this policy is to: Assist departments in effective utilization of space and efficient information retrieval; Establish guidelines for disposal of records; Establish the importance of the identification of Vital Records for the purpose of protection against and recovery from potential disaster situations; and Act as liaison between institutional management, The University of Texas (UT) System, and State Records Management in order to ensure compliance with the best possible records management procedures. POLICY STATEMENT It is the policy of The University of Texas MD Anderson Cancer Center (MD Anderson) to designate a Records Administrator. This responsibility is assigned to Records Management. Records Management establishes and maintains retention schedules that provide for effective space utilization, efficient information retrieval and identification, and protective procedures for Vital Records. SCOPE This policy applies to all departments responsible for maintaining effective procedures for records storage, retention, and retrieval. Compliance with this policy is the responsibility of all faculty, trainees/students, and other members of MD Anderson s workforce. TARGET AUDIENCE The target audience for this policy includes, but is not limited to, all faculty, trainees/students, and other members of MD Anderson s workforce. DEFINITIONS Non-Records: Documents made for the convenience of the organization and disposed of after use. Non- Records may include items such as: routing slips, transmittal sheets, temporary copies of correspondence, reading file copies of correspondence, duplicate copies of all documents in the same file, and notes. Non-Records are not to be listed in the records retention schedule. Page 1 of 6
Record Series: Any group of documents valuable enough to be retained for a specified period of time. The record can take several forms such as paper, computer printouts, magnetic tapes, micrographics, motion pictures, maps, and blueprints. Vital Records: Contain information essential to protect MD Anderson s rights and to continue to operate as a business entity. Consideration of a Record Series as vital implies an obligation that the record must be reasonably safeguarded against loss. PROCEDURE 1.0 Records Classification 1.1 Records are classified in one of the following groups: A. Archival: Records which have passed their active purpose but have possible long range value. B. Administrative: Legal, personnel, and support service records. C. Fiscal: Financial records. D. Scientific: Medical and research records. 1.2 Computer records may fit into any of the above categories. 1.3 Records Series may overlap more than one of these categories; however, they will be categorized based on their primary function at the time. 2.0 Record Life Cycle 2.1 The following steps describe the record life cycle: A. Creation. B. Distribution. C. Active Use. D. Inactive OR Storage. E. Destroy OR Archive. 2.2 Records follow this pattern but may not go through each step (i.e., a record may go from creation to active to destroy). Page 2 of 6
2.3 Records could change their value over their life cycle. A record may be classified as vital at inception and, once processed, may become a reference copy only. 2.4 A record may be highly confidential prior to or during an activity and, after the activity is completed, may be considered open information. 2.5 A record needs to be handled as vital and/or confidential only for the period of time that it is so classified. 3.0 Retention Schedules 3.1 Retention schedules will be established within the following guidelines: A. To comply with federal and state laws; and B. To meet federal and state audit requirements. 3.2 Texas State Library and Archives Commission and UT System mandated guidelines will be followed. Additional internal overriding functional usage requirements will be considered. If the Record Series is active, the retention schedule will be adjusted according to departmental needs. 3.3 A Record Series will be designated as permanent if it (1) could have historical value, (2) could be used to retrace trends of activities within the institution which may be deemed to have significant long-range information usable in such things as management reports and decisions, or (3) has potential medical/research value. 4.0 Record Storage 4.1 Records, which are actively accessed, will be located at the office site. 4.2 Inactive records series, which have not met their retention schedule, will be stored offsite. 5.0 Record Destruction Once records reach the inactive stage of their life cycle they will be destroyed, provided they have met their established retention requirement. 6.0 Micrographics 6.1 Micrographics will be implemented based on the length of retention and/or quantity/volume of space required. 6.2 Established retention/destruction schedules will apply to micrographic records (i.e., if a record is to be retained for years and destroyed, this applies to the micrographic copy, unless otherwise specified). 6.3 If the hard copy is to be retained for a specified number of years, then micrographed, the hard copy destroyed, and the micrographic copy retained for a longer period of time, this will be so stated in the retention schedule. Page 3 of 6
7.0 Vital Records 7.1 A backup duplicate copy at an alternate remote location to the primary record location will meet the test as a minimal reasonable safeguard and so stated in the retention schedule. 7.2 This additional time and effort cost will be justified if a record is vital to the institution. 7.3 Records, which are categorized as vital, will be identified to Records Management along with the backup recovery procedure to be included in the institutional disaster plan. Page 4 of 6
ATTACHMENTS/LINKS Retention Schedules. RELATED POLICIES None. JOINT COMMISSION STANDARDS / NATIONAL PATIENT SAFETY GOALS The hospital audits its medical records. Standard: RC.01.04.01. Comprehensive Accreditation Manual for Hospitals (CAMH), July 2013. The hospital retains its medical records. Standard: RC.01.05.01. Comprehensive Accreditation Manual for Hospitals (CAMH), July 2013. OTHER RELATED ACCREDITATION / REGULATORY STANDARDS None. REFERENCES Records Management Department. Texas State Library and Archives Commission, https://www.tsl.state.tx.us/landing/public.html. Page 5 of 6
POLICY APPROVAL Approved With Revisions Date: 08/07/2013 Approved Without Revisions Date: Implementation Date: 08/07/2013 Version: 22.0 RESPONSIBLE DEPARTMENT(S) Controller's Office Page 6 of 6