TITLE: Document Management Policy 1 APPLICABILITY: Workforce POLICY: R1029 I. PURPOSE The corporate documents of Wright State Physicians, Inc. (the "Corporation") are important assets of the Corporation. The purpose of this Document Management Policy and attached schedules ("Policy") is to ensure that the Corporation's documents are properly managed and maintained and that documents no longer of any value are timely and properly discarded. This Policy is intended to assist officers, directors, physicians, employees and volunteers of the Corporation in understanding their responsibilities for the management and maintenance of the Corporation's documents. This Policy includes schedules for the retention and destruction of specific categories of documents to ensure legal compliance, organizational efficiency, consistency and also to accomplish other objectives, such as cost management. Compliance with federal, state and local retention requirements will override all other objectives. II. APPLICATION Documents Generally. A "Document" is any record generated in the course of the Corporation's operation, whether in written, digitally recorded, electronically stored or other form, whether tangible or intangible. Examples of Documents include, but are not limited to: memoranda, electronic mail or "e-mail," facsimiles, contracts, forms, binders, recorded voice mail messages, calendars, photographs,.pdf files, receipts and computer files. Electronic Documents. Electronic Documents, or any Documents stored electronically, shall be treated under this Policy as if they were paper Documents. The retention period of an Electronic Document depends on the subject matter of the particular Document and shall be retained as listed on the appropriate retention schedule. In other words, the content of a Document determines how it is managed and retained, not the format of the Document. III. RESPONSIBILITY The Corporation expects all officers, directors, physicians, employees and volunteers to comply fully, consistently and diligently with this Policy. No officer, director, physician, employee, or volunteer of the Corporation shall deviate from Document Management Policy s, retention, and destruction set forth herein unless expressly instructed by the Corporation's Compliance Director or otherwise expressly provided herein (e.g., litigation relevant Documents). IV. COMPLIANCE AND POLICY ADMINISTRATION The Corporation's Chief Operating Officer shall be the Policy administrator and as such is the officer in charge of the administration of this Policy and the implementation of processes and procedures to ensure that the Policy is followed. The Compliance Director in consultation with the Chief Operation Officer, is authorized to: educate officers, directors, physicians,
2 employees and volunteers on the Policy; make modifications or additions to the Document retention schedules included in the Policy from time to time to ensure that the schedules are in compliance with local, state and federal laws; monitor or have monitored local, state and federal laws affecting Document retention; conduct scheduled periodic reviews of the Policy; and monitor compliance with the Policy. V. DOCUMENT CREATION Documents shall be created for the purposes and in the conduct of the business of the Corporation only. At no time should documents be created for personal purposes. Directors, officers, physicians, employees, and volunteers should refrain at all times from unprofessional, embarrassing, offensive or inflammatory communications, including those in electronic formats. VI. DOCUMENT RETENTION The law requires the Corporation to maintain Documents, depending on their content, usually for a specific minimum period of time. Failure to retain those Documents may subject directors, officers, physicians, employees, volunteers and the Corporation itself to penalties and fines, cause a loss of rights, obstruct justice, spoil potential evidence in a legal action, adversely impact the Corporation's position with regulatory authorities, place the Corporation in contempt of court, or seriously disadvantage the Corporation in the pursuit or enforcement of its legal rights. VII. DOCUMENT DESTRUCTION Generally. Designated Documents shall be destroyed annually during a period established by the Chief Operating Officer. All Documents that are not of a confidential or otherwise nonpublic nature may be destroyed by any feasible means. All confidential or otherwise nonpublic Documents shall be shredded or destroyed using appropriate alternative means to the extent necessary to ensure the continued privacy of the information contained therein and to ensure compliance with applicable law included within the limitations of HIPAA and the Fair Credit Reporting Act. Electronic records shall be destroyed by a method most appropriate to the storage media, ensuring the continued privacy of information contained therein when necessary. Exception for Litigation, Investigation, or Audit Relevant Documents. Any Corporate Documents that are relevant to litigation, potential litigation (i.e., a dispute that could result in future litigation), an investigation or audit by a regulatory or other authority or that are responsive to any legal request for the Documents, including but not limited to a subpoena, in each case, as determined by the Compliance Director, shall be preserved according to the Compliance Director's instructions until the Compliance Director advises that the Documents are no longer needed. Officers, directors, physicians, employees or volunteers must report any event they believe would require the preservation of Documents for litigation,
3 investigation, audit or legal purposes, as described herein, to the Chief Operating Officer, in consultation with the Compliance Director, immediately, who shall evaluate the circumstances and, if appropriate, take steps to inform promptly all necessary individuals to preserve such Documents and otherwise suspend any applicable destruction schedule. This exception supersedes any previously or subsequently established destruction schedule for the Documents. VIII. SCHEDULES Attached as Appendix A is a Document Retention Schedule. This schedule sets forth the minimum retention periods for major classes of Documents. If an Officer, director, physician, employee or volunteer is unsure under which category a Document falls, he or she should consult with the Chief Operating Officer in consultation with the Compliance Director.
4 APPENDIX A The following document retention schedule is a list of common record types found at Wright State Physicians and the recommended time period they should be kept. A. Accounting and Finance Annual Budgets Account Payable ledgers and schedules Accounts Receivable ledgers and schedules Annual Audit Reports and Financial Statements Accounts Payable Accounts Receivable Accounts Receivable-Credit Cards Cash Records Collection records Annual Financial reports Payroll Records Tax Returns and Worksheets (e.g. form 990, 990-PF, 990- EZ, or 990-T) State and local exemption applications relating to sales and use tax and personal property tax Bad Debt Banking Documentation Chart of Accounts Reimbursement Documentation While active plus 6 years
5 B. Contracts Contracts and any amendments thereof (including any purchase orders or invoices that serve as contracts for an item or service) Term of contract plus 15 years C. Corporate Documents/General Administrative Records Minute Books, Signed Minutes of the Board and all committees. Audio or Video Recordings of Meetings Organizational Charts Publications Advertising- records related to marketing and promoting image and activities Agendas Annual Reports Audits, Internal Strategic Plans Training Course Documentation Destroy when reduced to writing Retain while active plus 10 years. Destroy when no longer in use 5 years Destroy 30 days after approval of the minutes While current plus 10 years Until superseded D. Correspondence and other Internal Memoranda General Principle: most correspondence, internal memoranda and general files should be retained for the same period as the Document to which they pertain or support. For instance, a letter pertaining to a particular contract would be retained as long as the contract (15 years after expiration). Correspondence, internal memoranda, and other general files or memoranda that do not pertain to Documents specifically identified in the Policy should be retained as follows; General Correspondence General Files (including general reports, emails and publications) 1 year 1 year
6 E. Personnel and Payroll Documents Personnel files Period of employment plus 10 years Training records Background checks of hired personnel Disciplinary Documentation Retirement and Pension records Time Records With-holding tax statements Records for Commissions, Bonuses, Incentives, and Awards Job Descriptions Forms; I-9, Forms; W-4 Employee Manuals/Handbooks Workforce Surveys Position Vacancy Announcements Discipline/Grievance Files Recruitment Records-Workforce search Medical Enrollment Forms Employment application of hired staff Employment application of non hired staff Declination files; includes contracts, recommendations, and letters of people who have declined positions Period of employment plus Period of employment plus Period of employment plus Period of employment plus Period of employment plus 3 years Period of employment plus Retain in office until superseded. Transfer 1 dated paper copy of each version to the Archives Retain collected questionnaires until results compiled and then destroy. Retain original questionnaire and survey report for 2 years 2 years Place in personnel file; period of employment plus 2 years Period of employment plus 3 years Place in personnel file; Period of employment plus 2 years 2 years
7 Employee selection Files; includes vitae, letters, records of individuals who have applied for faculty and staff positions Disciplinary Documentation Evaluations Place in personnel file; period of employment plus 2 years Place in personnel file; period of employment plus Place in personnel file; period of employment plus F. Employee Benefit Plan Documents Any Determination letters for Retirement Plans Any formal Benefit Plan Documents Forms 5500 Summary Annual Reports G. Property Documents Original Purchase, Sale, or Lease Agreement Property Insurance Policy 15 years 15 years H Legal Documents Legal memoranda and Opinions; legal correspondence unrelated to litigation, investigations, or audits Documents related to Litigation, Potential, or investigation or Audit by a Regulatory or Other Authority (including files, legal memoranda, opinions, and correspondence related thereto) Court Orders Contracts General Trademark Retain for the same period as the Document identified in this Policy to which it relates According to Compliance director instructions During their term plus 15 years following the longer of (x) period of registration or (y) period of use
8 Copyright I. Information Technology Records Data systems Backup Files; copies of master files or databases, application software, logs, directories, and other documentation needed to restore a system in case of disaster or disruption Data systems Equipment Support Files: information on data processing equipment, software, and other products and their vendors. Record of support services provided for specific data processing equipment, including site visit reports, service reports, service histories, and correspondence Data Systems Usage Files: Records created to monitor computer system and network usage, including but not limited to log-in files, system usage files, data entry logs, and records of individual computer program usage Retain for 2 backup cycles Retain while active + Retain 1 year J. Medical Record Medical Record; includes but not limited to; billing records, clinical encounter notes, referral information, correspondence, coordination of care documentation Adult Patients 10 years Adult Patients with mental competency restored 10 years Minor Patients 2 years past age of majority OB Patients - involving impaired infant, maintain 2 years past infant age of majority. Otherwise, maintain as Adult Patient retention schedule