North York General Hospital Policy Manual

Transcription

1 TITLE: Record Retention and Destruction Policy NUMBER: V 50 Legal Health Record Policy, V-80 ORIGINATOR: Maria Muia, Director, HIM ORIGINAL DATE APPROVED: June, 1995 APPROVED BY: Medical Advisory Committee DATE REVIEWED/REVISED: June, 2009 Operations Committee DATE OF IMPLEMENTATION:Nov 9, 2009 POLICY: PAGE 1 OF 22 North York General Hospital (NYGH) will maintain, retain and securely dispose of records (please see below) in accordance with applicable federal and provincial statutes and NYGH policies including the Privacy and Data Protection Policy. With respect to this policy, the term records is meant to include: All records containing personal health information Health records Records associated with unit or program operations Records pertaining to patient/family complaints Incident reports Corporate or administrative records Financial records Human Resources records Staff working with the various types of records should have a working knowledge of the legislative requirements that govern the maintenance, retention and disposal of records they are working with. Retention All records as outlined below, regardless of physical form or characteristics, will be retained according to the retention period set out in applicable legislation or longer if necessary to meeting our legal, financial or administrative obligations. It is recognized that different types of records governed by different pieces of legislation may require retention for different periods of time. Records will be maintained in accordance with the stipulations of the applicable legislation. Additional safeguards will be utilized for especially sensitive information. (Refer to inventory of health records for location of records. Note: the inventory is stored in health records shared drive). Destruction Once the retention period has been reached, North York General Hospital will securely dispose of records in accordance with applicable laws and policies. Destruction of hard copy records including personal health information will be through fine shredding or incineration. Destruction of electronic records (and other media), excluding personal health information, will be subject to current, Information Technology (IT) approved, processes which ensure that reconstruction of the information is not reasonably foreseeable in

2 Legal Health Record Policy, V-80 PAGE 2 OF 22 the circumstances. A log of all records of Personal Health Information destroyed will be maintained regardless of whether the record is in hardcopy or electronic form (Appendix A). Related Documents Privacy and Data Protection Policy, V-25 Legal Health Record Policy, V-80 Inventory of Health Records at North York General Personal Health Information Protection Act Regulated Health Professions Act Associated statutes pertaining to each of the regulated health professions Regulations of each of the Ontario Colleges [regulated health professions] Regulations of the College of Social Workers & Social Service Workers Freedom of Information Act Corporations Act Income Tax Act Definitions Personal health information (PHI) refers to all health related information [as defined in the legislation & outlined below] that is linked to identifying information about an individual in either oral or recorded form. Health related information is defined in the legislation as information that relates to the: physical or mental health of an individual including the medical history of their family members; The health care provided to an individual The plan of service under the Long-Term Care Act, 1994; payments or eligibility for health care of an individual; donation of a body part or bodily substance of an individual or derived from testing or examination of any such body or bodily substance; An individual s health number; Identification of 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, offer letter, resume/application form, name, address, telephone number, social insurance number, date of birth, next of kin/person to notify in an emergency, and Personnel Action Forms indicating salary, status revisions and dates, professional/technical registration numbers, copies of all correspondence, performance appraisals, outline of employment benefits and related documents, Statement of Confidentiality. 2 1 Definition from the Protection of Personal Health Information policy 2 Definition from the Employee Records policy

3 Legal Health Record Policy, V-80 PAGE 3 OF 22 Policy Details 1.0 Retention Patient Care Records Original Hardcopy Health Records where an electronic copy is available (i.e. original is scanned into the Electronic Health Record) Records associated with Unit/Program Operations Incident Reports & Patient Complaints Corporate/Administrative Records Financial Records Human Resources Records Laboratory Medicine Genetics Program 2.0 Destruction 2.1 Hardcopy Records 2.2 Original Hardcopy Health Records where an electronic copy is available 2.3 Electronic Records

4 Legal Health Record Policy, V-80 PAGE 4 OF 22 PROCEDURE/ GUIDELINE: 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 (whether hard copy, electronic or microfilm). 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 Department Responsible: Health 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 Permanent Public Hospitals Act Reg. 965 Permanent

5 Legal Health Record Policy, V-80 PAGE 5 OF 22 Type of Information Age of Patient/Criteria Minimum Retention by law Statute or Regulation NYGH Retention Rule Health Record 3 (Personal Health Information) In-Patient or Outpatient who is 18 years or older 10 years after discharge or death of the patient Public Hospitals Act Reg. 965, s.20 (3) (b) 10 years (including Diagnostic Imaging Exam of the Breast) In-Patient/Out-patient who is less than 18 years old including Fetal Monitoring Strips 4 10 years after the 18 th birthday of the patient Public Hospitals Act Reg years Deaths: In-Patients, Out-Patients N/A N/A 10 years Deaths: Nursing Homes N/A Nursing Homes Act Reg. 832, s.90 (b) 5 years Residents of nursing homes that are discharged N/A Nursing Home Act Reg. 832, s.90 (a) 20 years 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 Fetal Monitor Strips are stored electronically in the OBIX obstetrical information system. A copy of the media is also stored in Health Records

6 Legal Health Record Policy, V-80 PAGE 6 OF 22 Type of Information Age of Patient/Criteria Minimum Retention by law Statute or Regulation NYGH Retention Rule Log and Request To Destroy Personal Health Information & Validation of Destruction Life of Hospital + 5 years Logs shall be retained in accordance with the by-laws of the hospital Public Hospitals Act, R.R.O Regulation 965, s. 21 (3) Life of Hospital + 5 years Release of Information Requests 10 years, or 10 years from patient s 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 *** 5 28 years Case report forms related to clinical trials N/A Until notified by researcher no longer required Diagnostic Imaging Record of a patient, excluding imaging exam of the breast. Patient is 18 years old or older Patient is under 18 years of age 5 years after the day on which the diagnostic imaging record is created 5 years after the 18 th birthday of the patient Public Hospitals Act Reg. 965 Public Hospitals Act Reg years 5 years from the patient s 18 th birthday 5 Guidance for Records Related to Clinical Trials (GUIDE-0068)

7 Legal Health Record Policy, V-80 PAGE 7 OF Original Hardcopy Health Records where an electronic copy is available (i.e. original is scanned into the Electronic Health Record) Department Responsible: Health Records 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 30 days 1.3 Records associated with Unit/Program Operations Department Responsible: Individual Unit/Programs 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 Drugs and Pharmacies Regulations Act 3 years Log Books/Sheets including telephone, paging logs, work orders and service reports Not applicable Not specified None 3 years Daily checklists of patients Not applicable Not specified None 30 days

8 Legal Health Record Policy, V-80 PAGE 8 OF Incident Reports, Patient Complaints, Risk Management Records Department Responsible: Risk Management 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 Department Responsible: Administration Type of Information Minimum Retention Period Statute or Regulation Comments Documents of Incorporation Life of hospital + 5 years Corporations Act, s.300

9 Legal Health Record Policy, V-80 PAGE 9 OF 22 Type of Information Minimum Retention Period Statute or Regulation Comments Commercial Agreements including leases Life of agreement + 2 years Agreements involving patient care 15 years N/A OHA Guidelines - Record Retention Tool Kit Limitations Act, s.4 and s.15 Life of Agreement + 6 years Agreements involving patient care should be kept longer between 2 and 15 years from date of expiry. Care should be taken to retain agreements with specific provisions (e.g. confidentiality and indemnity) that survive termination of contract Agreements with clauses that survive termination of agreements Permanent or as otherwise specified in the agreement Limitations Act, s.4 and s.15 OHA Record Retention Tool Kit (C11) Deeds Life of Hospital + 5 years N/A Board Policies Life of hospital + 5 years N/A Board By-Laws Life of hospital + 5 years N/A Accreditation Records Life of hospital + 5 years N/A Annual Reports Life of hospital + 5 years N/A Board Member Lists Life of hospital + 5 years Corporations Act, s.300 Board Minutes Life of hospital + 5 years N/A

10 Legal Health Record Policy, V-80 PAGE 10 OF 22 Type of Information Minimum Retention Period Statute or Regulation Comments Board Committee Minutes Life of hospital + 5 years Corporations Act, s.299 and s.304 Strategy Team (Executive) Minutes Life of hospital + 5 years Corporations Act 269(2), s.299 and s.300 Health & Safety Committee Current year + minimum of 6 years Reasonable practice Corporation Member List 10 years N/A Medical Advisory Committee 10 years N/A Patient Care Quality Committee 10 years N/A Health Records Committee 15 years N/A OHA recommends 15 years for minutes of committees relating to patient care, such as Medical Records, Patient Care, Infection Control and Utilization Committees. Pharmacy & Therapeutics 10 years N/A Other Clinical/Patient Care Committees 10 years N/A Other administrative Committees 10 years N/A Hospital Policies 15 years OHA Guidelines - Records Retention Tool Kit

11 Legal Health Record Policy, V-80 PAGE 11 OF 22 Type of Information Minimum Retention Period Statute or Regulation Comments Insurance Policies 15 years OHA Guidelines - Records Retention Tool Kit Medical Staff Life of hospital + 5 years By Law, Rules & Regulations Elevator Log Books Date of last entry + 5 years Elevating Devices Regulation under the Technical Standards & Safety Act, s.34 Fire Safety Tests & Inspections Test / inspection date + 2 years Fire Code under Fire Protection & Prevention Act, ss.2.8, 6.2, 6.7 and Financial Records Department Responsible: Finance All financial records must be kept for a minimum of 2 years from the date of dissolution of a corporation. (Income Tax Act) Type of Information Minimum Retention Statute or Regulation Comments General Audited Annual Financial Statements Life of hospital + 5 years Income Tax Act, s.230 Corporations Act, s.302

12 Legal Health Record Policy, V-80 PAGE 12 OF 22 Type of Information Minimum Retention Statute or Regulation Comments Annual Financial Returns Life of hospital + 5 years Income Tax Act, s.230 Corporations Act, s.302 General Ledger Life of hospital + 5 years Income Tax Act, s.230 Corporations Act, s.302 Annual Adjusting Journal Entries Life of hospital + 5 years Income Tax Act, s.230 Corporations Act, s.302 Year End Audit Working File 20 years N/A Cheque Register 7 years N/A Cash Receipts Register 7 years N/A Income Register 7 years N/A Internal Financial Results 7 years N/A Departmental Budgets 5 years N/A Payroll t-4 Slips 6 years N/A Following the year for which they are kept Payroll Register 6 years N/A Following the year for which they are kept

13 Legal Health Record Policy, V-80 PAGE 13 OF 22 Type of Information Minimum Retention Statute or Regulation Comments Employee Earning Record, Payment Records Payroll deduction authorization records 6 years Employment Insurance Act (Canada), ss.87(3) 6 years Income Tax Act, s.230 Income Tax Act Regulation, s.5800 Following the year for which they are kept From end of tax year (fiscal period) to which they relate HOOPP Records - individual employee deductions Union Dues Deduction Records Permanently Ontario Pension Benefit Act 6 years Income Tax Act, s.230 Income Tax Act Regulations, s.5800 From end of tax year (fiscal period) to which they relate, except where collective agreement states otherwise Worker s Compensation Board Invoices 7 years N/A No statutory provisions however the Board may request previous records. Revenue Including Accounts Receivables) Revenue Journals 7 years N/A

14 Legal Health Record Policy, V-80 PAGE 14 OF 22 Type of Information Minimum Retention Statute or Regulation Comments OHIP Billing Information Date of record + minimum 10 years Patient s Ledger Cards 7 years N/A Cash Receipts 7 years N/A Health Insurance Act, s.37.1 requires retention of records but does not specify a retention period. OHA record retention tool kit suggests date of record + minimum 10 years Midnight Census 2 years OHA Guidelines Record Retention Tool Kit Patient Charge Slips 2 years N/A Consistent with retention period for patient care records Daily Cash Work Sheets to support deposits to banks (kept in patient accounts) 1 year N/A 7 years? Bank Deposit Slips or Books 7 years N/A

15 Legal Health Record Policy, V-80 PAGE 15 OF 22 Type of Information Minimum Retention Statute or Regulation Comments Accounts Payable AP Journal 7 years N/A Copy of cheque 7 years N/A Cancelled Cheques 7 years N/A Bank Statements 7 years N/A Bank Reconciliations 7 years N/A Sub-Ledger 7 years N/A Land Acquisition Invoices Permanent Business Corporations Act Capital Equipment Records 20 years N/A Permanent until item is disposed of? 1.7 Procurement Records Type of Information Minimum Retention Statute or Regulation Comments Purchasing Department Requisitions 5 years N/A

16 Legal Health Record Policy, V-80 PAGE 16 OF 22 Type of Information Minimum Retention Statute or Regulation Comments Copy of Purchase Orders Supplies Copy of Purchase Orders Capital Tenders (RFP, RFQ, RFI) and Correspondence 2 years N/A Supply orders are paperless and stored in the MM system 10 years N/A 5 years N/A Packing Slips 2 years N/A Central Supply Room Central Supply Requisitions 1 year N/A Check Slips 1 year N/A

17 Legal Health Record Policy, V-80 PAGE 17 OF Human Resources Records Department Responsible: Human Resources Type of Information Minimum Retention Statute or Regulation Comments Employee Record 3 years Employment Standards Act, s.15 After employee terminates. If employee is under 18, 3 years after 18 th birthday.? Time Cards/Records 3 years Canada Labour Code After work is performed or employee terminates NYGH stores time card information on Kronos since 2006 and archived information is accessible for at least 3 years OHIP deduction records, billing records 6 years Income Tax Act, s.230 Exemption records 7 years N/A Income Tax Act Regulation, s.5800 From end of tax year (fiscal period) to which they relate HOOPP Records, individual employee deductions Employment Insurance Records Permanently Ontario Pension Benefit Act 6 years N/A

18 Legal Health Record Policy, V-80 PAGE 18 OF 22 Type of Information Minimum Retention Statute or Regulation Comments Miscellaneous Employment records and Documents Creation date + minimum of 2 years Employee Standards Act, s.15 3 years (Examples include: employment offer letters and contracts, performance reviews and discipline notices, information regarding raises, promotions and employee complaints, responses and investigation notes Physicians Applications (rejected) 2 years Limitations Act, s.4 Physicians Appointment Records End of appointment year + 6 years Reasonable Practice/Limitations Act, s.4 and s.15 Hiring and Interview Notes 1 year Ontario Human Rights Commission Recommendation Occupational Health & Safety Employee Education Program 2 years Canada Occupational Safety and Health Regulations After employee stops working with the particular substance or work area.

19 Legal Health Record Policy, V-80 PAGE 19 OF 22 Type of Information Minimum Retention Statute or Regulation Comments Occupational Health & Safety Records Current year + minimum 6 years Limitations Act, s.4 and s.15 Reasonable practice Inspection Reports, Ministry of Labour Investigative Reports on Hazardous Substances Annual Workplace Inspections 10 years N/A 2 years N/A 2 years N/A Workplace Accident/Injury Incident Investigation Records Creation year + minimum 6 years Workplace Safety & Insurance Act Reasonable practice Minutes of Joint Health and Safety Committee Current year + minimum 6 years Limitations Act, s.4 and s.15 Reasonable practice Material Safety Data Sheet Date of expiry + minimum 2 years Limitations Act, s.4 and s.15 Notice of accidents and records relating to confined spaces, lifting or selfpropelled mobile equipment, autoclave/sterilization machinery, and lifting equipment 1 year or longer to ensure that the two most recent reports or records are on file Healthcare & Residential Facilities Regulation, s.4 (Regulation 67/93 under Occupational Health & Safety Act)

20 Legal Health Record Policy, V-80 PAGE 20 OF Laboratory Medicine Please refer to Retention of Documents, Records, Specimens and Material PM Genetics Program Please refer to Retention of Documents, Records, Specimens and Material GM

21 Legal Health Record Policy, V-80 PAGE 21 OF Destruction Procedure 2.1 Permanent 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 will approve the destruction prior to commencing the procedure. The destruction of any Personal Health Information will be completed in collaboration with the Director of Health Information Management (HIM) or designate. The log and Request to Destroy Personal Health Information and Validation of Destruction (Appendix A) will be signed and dated by the Director of the Program responsible for destroying the records and by the Director of HIM, or designate. The Master Patient Record which is retained permanently will serve as the log where records are destroyed. Hardcopy records will 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. (Legal Health Record Policy) Patient level detail logs are not required as the electronic document replaces the hardcopy as the original document. 2.3 Electronic Records Electronic records (i.e., Cerner, PACS) which have passed the NYGH Retention time period will 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.

22 Legal Health Record Policy, V-80 PAGE 22 OF 22 Appendix A Log and Request to Destroy Personal Health Information & Validation of Destruction Date: Service Provider: Log of Records for Destruction (must include the names of the patients to whom the records of personal health information refer; and the date and manner of destructions). The log can be electronic or hard copy.: Dates of Records for Destruction: Exclusions of Records for Destruction: Approval of Program Director: Program Approval by Director, Health Information Management: Dear Service Provider: To ensure the privacy of records containing any personal health information, please complete the required information below to validate the destruction of the records identified above. validates that the above named records have been company name received from, North York General Hospital program and have been destroyed by. preferred method of destruction: fine shredding/silver recovery, incineration Signed by, at this signature please print name time day of 20. date month year Please retain a copy for your files and return the signed original to:, North York General Hospital, 4001 Leslie Street, Toronto, ON M2K 1E1 Program