Data Retention Policy
Policy Name:
/ Data Retention PolicyEffective Date:
ReviewDate:
Responsible Department:
/ Information SystemsSupporting Documents:
Summary
The Vancouver Clinic (TVC) has adopted this Data Retention Policy to insure the proper handling of its data.
I.Purpose
To ensure the most efficient and effective operation of The Vancouver Clinic (“TVC”), we are implementing this Document Retention Policy (“DRP” or“policy”). The records of TVC and its subsidiaries are important to the properfunctioning of TVC. Our records include virtually all of the records you produce asa TVC employee. Such records can be in electronic or paper form. Thus, itemsthat you may not consider important, such as interoffice emails, desktop calendars andprinted memoranda are records that are considered important under this policy. If you areever uncertain as to any procedures set forth in this policy (e.g., what records to retain ordestroy, when to do so, or how) it is your responsibility to seek answers from TVC’sDRP Manager.
The goals of this DRP are to:
1. Retain important documents for reference and future use;
2. Delete documents that are no longer necessary for the proper functioning of
TVC;
3. Organize important documents for efficient retrieval; and
4. Ensure that you, as a TVC employee, know what documents should beretained, the length of their retention, means of storage, and when and how theyshould be destroyed.
Federal and state laws require TVC to maintain certain types of records forparticular periods. Failure to maintain such records could subject you and TVC topenalties and fines, obstruct justice, spoil legal evidence, and/or seriously harmTVC’s position in litigation. Thus, it is imperative that you fully understand andcomply with this, and any future records retention or destruction policies and schedules,UNLESS you have been notified by TVC, or if you believe that (1) such records areor could be relevant to any future litigation, (2) there is a dispute that could lead to litigation,or (3) TVC is a party to a lawsuit, in which case you MUST PRESERVE suchrecords until TVC’s legal counsel determines that the records are no longer needed.
“Records” discussed herein refers to all business records of TVC (and is used interchangeably with “documents”), including written, printed, and recorded materials, as well as electronic records (i.e., emails and documents saved electronically). All business records shall be retained for a period no longer than necessary for the proper conduct and functioning of TVC. No business records shall be retained longer than five (5) years, EXCEPT those that (1) have periods provided for herein, (2) are in the Document Retention Schedule, found at Appendix “A”, or (3) are specifically exempted by TVC’s DRP Manager.
- Management
To ensure compliance with this DRP, TVC’s DRP Manager is responsible for the following oversight functions:
• Implementing the DRP;
• Ensuring that employees are properly educated, understand, and follow the DRP’s purpose;
• Providing oversight on actual retention and destruction of documents;
• Ensuring proper storage of documents;
• Periodically following-up with counsel to ensure proper retention periods are in place;
• Ensuring the proper storage of documents;
• Suspending the destruction of documents upon foreseeable litigation; and
• Keeping corporate officers, directors, and employees apprised of changes in relation to the DRP.
TVC’s DRP Manager shall annually review the DRP, modify it accordingly, and inform and educate all TVC employees on any such changes. All questions relating to document retention and/or destruction should be directly addressed to TVC’s DRP Manager
- Types of Records
Appendix “A”, attached at the end of this DRP, lists several categories of records, as well as specific records that contain specific retention periods. This is referred to as a Document Retention Schedule (“DRS”). All records not provided for in the DRS or described herein, shall be classified into three types, (1) Temporary Records, (2) Final Records, and (3) Permanent Records.
Temporary Records
Temporary records include all business documents that have not been completed. Such include, but are not limited to written memoranda and dictation to be typed in the future, reminders, to-do lists, report, case study, and calculation drafts, interoffice correspondence regarding a patient or business transaction, and running logs.
Temporary records can be destroyed, or permanently deleted if in electronic form (see protocol below for proper destruction of data in electronic form) when a project/case/file closes. Upon the closing of a project/case/file, gather and review all such temporary records. Before you destroy or permanently delete these documents, make sure you have duplicates of all the final records pertaining to the project/case/file.
Final Records
Final records include all business documents that are not superseded by modification or addition. Such include, but are not limited to: documents given (or sent via electronic form) to any third party not employed by TVC, or government agency; final memoranda and reports; correspondence; handwritten telephone memoranda not further transcribed; minutes; design/plan specifications; journal entries; cost estimates; etc. All accounting records shall be deemed final.
Except as provided for in the DRS, all final documents are to be discarded ten (10) years after the close of a project/case/file.
Permanent Records
Permanent records include all business documents that define TVC’s scope of work, expressions of professional opinions, research and reference materials. Such include, but are not limited to contracts, proposals, materials referencing expert opinions, annual financial statements, federal tax returns, payroll registers, copyright registrations, patents, etc.
Except as provided for in the Document Retention Schedule (Appendix “A”), all permanent documents are to be retained indefinitely.
Accounting and Corporate Tax Records
Accounting and corporate tax records include, but are not limited to: financial statements;ledgers; audit records; invoices and expense records; federal, state, and property tax returns;payroll; accounting procedures; gross receipts; customer records; purchases; etc.
Unless otherwise specified in the DRS, such records should be retained for the minimum ofsix (6) years or until the statute of limitations for a particular record expires (please consult TVC’s counsel for time periods if you manage/control such records).
Workplace Records
Workplace records include, but are not limited to Articles of Incorporation, bylaws, meetingminutes, deeds and titles, leases, policy statements, contracts and agreements, patents andtrademark records, etc.
Unless otherwise specified in the DRS, such records should be retained inperpetuity.
Employment, Employee, and Payroll Records
Employment records include, but are not limited to job announcements and advertisements;employment applications, background investigations, resumes, and letters ofrecommendation of persons not hired; etc.
Unless otherwise specified in the DRS, such records should be retained for the minimum ofone (1) year.
Employee records include, but are not limited to employment applications, backgroundinvestigations, resumes, and letters of recommendation of current and past employees,records relating to current and past employee’s performance reviews and complaints, etc.
Unless otherwise specified in the DRS, such records should be retained for the minimum ofthree (3) years following unemployment with TVC.
Payroll records include, but are not limited to wage rate tables; salary history; current rate ofpay; payroll deductions; time cards; W-2 and W-4 forms; bonuses; etc.
Unless otherwise specified in the DRS, such records should be retained for the minimum ofsix (6) years.
Bank Records
Bank records include, but are not limited to bank deposits; check copies; stop paymentorders; bank statements; check signature authorizations; bank reconciliations; etc.
Unless otherwise specified in the DRS, such records should be retained for the minimum ofthree (3) years.
Legal Records
Legal records include, but are not limited to all contracts, legal records, statements, andcorrespondence, trademark and copyright registrations, patents, personal injury records andstatements, press releases, public findings, etc.
Unless otherwise specified in the DRS, such records should be retained for the minimum often (10) years.
Historical Records
Historical records are those that are no longer of use to TVC, but by virtue of theirage or research value may be of historical interest or significance to TVC.
Historical records should be retained indefinitely.
- Storage
Tangible Records
Tangible records are those in which you must physically move to store, such as paperrecords (including records printed versions of electronically saved documents), photographs,audio recordings, advertisements and promotional items. Active records and records thatneed to be easily accessible may be stored in TVC’s office space or equipment.
Inactive records can be sent to TVC’s off-site storage facility.
Electronic Records
Electronic mail (“E-mail”) should be either printed and stored as tangible evidence, ordownloaded to a computer file and kept electronically or on a disk.
TVC has computer software that duplicates files, which are then backed-up oncentral servers. If you have a notebook computer from TVC that you work on outof the office, it is important that all employees takeprecautionary measures to save work and records on TVC’s network drive.
If you save sensitive or important records on computer disks, you should duplicate theinformation in an alternate format because disks are easily lost or damaged.
- Destruction / Deletion
Tangible Records
Tangible records should be destroyed by shredding or some other means that will renderthem unreadable. If you have a record that you do not know how to destroy, such as aphotograph, compact disk, or tape recording, ask the advice of TVC’s DRP
Manager.
Electronic Records
E-mail records that you “delete” remain in Organization’s system. Thus, TVC’sinformation technology (“IT”) department will be responsible for permanently removingdeleted emails from the computer system.
Deleting files and emptying the recycling bin is usually sufficient in most circumstances toget rid of a record. However, because electronic records can be stored in many locations, TVC’s IT department will be responsible for permanently removing deleted filesfrom the computer system.
Keep in mind, where duplicate records are involved, both copies must be destroyed/deletedwhere proper.
- Cessation of Record Destruction/Deletion
If a lawsuit is filed or imminent, or a legal document request has been made upon TVC, ALL RECORD DESTRUCTION MUST CEASE IMMEDIATELY.
TVC’s DRP Manager may suspend this DRP to require that documents relating tothe lawsuit or potential legal issue(s) be retained and organized. A critical understanding ofthis section is imperative. Should you fail to follow this protocol, you and/or TVC may be subject to fines and penalties, among other sanctions.
Appendix ADocument Retention Schedule
Department / Document Type / On Line / Quick Access Retrieval / Max Storage Time / Regulatory or Preference / Archived Retrieval SLAAdministration / Board minutes / 7 Years / Permanent / Preference / 2 Weeks
Administration / Terminated contracts / 3 Years / 7 Years / Preference / 2 Weeks
Administration / Merger paperwork / 3 years / 7 Years / Preference / 2 Weeks
Administration / Various meeting minutes (i.e.Finance, Strategic Planning) / 3 Years / 7 Years / Preference / 2 Weeks
All clinical departments / Provider schedules / 3 years
/ 10 Years / Regulatory Medicare / 2 Weeks
Ancillary Departments / Physicians Orders / 7 years / Permanent / Regulatory Medicare / 1 Week
Business Services / Refund Documentation / 3 years / 7 Years / Regulatory / 2 Weeks
Business Services / EOB's / 3 years / 7 Years / Regulatory / 2 Weeks
Business Services / Adjustment Batches / 3 years / 7 Years / Preference / 2 Weeks
Business Services / Patient Account Information / 3 years
/ 10 Years / Regulatory Medicare / 2 Weeks
Business Services / Collection Letters & Budget Agreements / 3 Years / 7 Years / Regulatory / 2 Weeks
Business Services / Fee schedules / 3 Years
/ 10 Years / Regulatory Medicare / 2 Weeks
Business Services / Vouchers & payment docs / 3 years / 2 Weeks / Regulatory / 2 Weeks
Business Services / Waivers &ABN's / 3 years / 2 Weeks / Regulatory Medicare / 2 Weeks
Business Services / Encounter Forms / 3 years / 2 Weeks / Regulatory / 2 Weeks
Business Services / Authorization to bill insurance and release medical info / 3 years / 2 Weeks / Regulatory Medicare / 2 Weeks
Cardiology / Tech worksheets and measurements on stress treadmills and nuclear studies / 7 Years / Regulatory, litigation
Department / Document Type / On Line / Quick Access Retrieval / Max Storage Time / Regulatory or Preference / Archived Retrieval SLA
Cardiology / Echo tapes / 7 Years / Permanent / Regulatory, litigation / 2 Weeks
Cardiology / Holter and King of Hearts Strips and worksheets / 7 Years / Permanent / Regulatory Medicare / 2 Weeks
Central Sterile / Cidex solutions records / 7 years / Permanent / Regulatory OSHA / 2 Weeks
Central Sterile / Sterilization bacteria logs / 7 Years / Regulatory OSHA
Central Sterile / Sterilization records / 7 years / Regulatory OSHA
Claims & Analysis / Check run batches / 7 years / Regulatory PacifiCare
Claims/Resource Management / Provider Contracts / 7 years>term / Preference
Facilities / Boiler Inspections / 2 years / Preference
Facilities / Fire Marshal inspections / 2 years / Preference
Facilities / Elevator Logs / 5 years / Regulatory state law
Finance / Depreciation records / 7 years / Regulatory IRS
Finance / Cash management documentation / 7 years / Regulatory IRS
Finance / Bank reconciliation / 7 years / Regulatory IRS
Finance / Journal documentation / 7 years / Regulatory IRS
Finance / Account receivable documentation / 7 years / Regulatory IRS
Finance / Financial statements / 7 years / Regulatory State
Finance / Audit reports / Indefinite / Regulatory IRS
Finance / Tax returns / Indefinite / Regulatory IRS
Finance / Fixed asset records / Indefinite / Preference
Department / Document Type / On Line / Quick Access Retrieval / Max Storage Time / Regulatory or Preference / Archived Retrieval SLA
Finance / Accounts payable records / 7 years / Regulatory IRS
Finance / Contracts and agreements / 7 years from end of contract / Preference
Finance / Annual back-up of financial software / Indefinite / Preference
Finance / MD Compensation records / 7 years / Preference
Finance / Payroll reports / 4 years / Regulatory
Finance / Time cards / 2 years / Regulatory
Finance / Garnishment records / 7 years / Regulatory IRS
Finance / Pension records / Indefinite / Preference
Finance / Property
Excise tax work papers / 7 years / Regulatory State
Finance / W2 forms and payroll taxes / 4 years / Regulatory IRS
Human Resources / Payroll personal change report / 6 years from hire or 1 year from termination / Regulatory state
Human Resources / Job applications / 1 Year / Preference
Human Resources / 401K Profit sharing report / 1 year / Preference
Human Resources / 401k Loan Documents / Until loan is paid / Regulatory state
Human Resources / Employee termination records / 6 years after date of termination / Regulatory state
Human Resources / Historical Benefit Information / 2 years / Preference
Human Resources / Employee Accident Reports / 30 years / Regulatory
Human Resources / Master control / 6 years / Preference
Department / Document Type / On Line / Quick Access Retrieval / Max Storage Time / Regulatory or Preference / Archived Retrieval SLA
Human Resources / I-9 / 3 years from hire or 1 year from term / Regulatory
Human Resources / Benefits 401K enrollment forms / 6 years from term / Regulatory
Human Resources / Employee accident annual summary / 30 years / Regulatory state
Information Systems / Software Licenses / Lifetime of the software / Regulatory Federal Laws
Information Systems / Back-up tapes of all servers / Point in time / Preference
Information Systems / Sleep Center study data / 15 years / Regulatory state
Information Systems / Media Destruction Records / 6 years / IS internal policy
Laboratory / Procedure Manuals / Indefinite / Regulatory Medicare
Laboratory / Instrument print-out tapes / 7 years / Regulatory CLIA
Laboratory / All Lab test results / 7 years / Regulatory Medicare
Laboratory / All hard copy original lab orders / 7 years / Regulatory Medicare
Laboratory / Parallel and Validation Studies / 7 years / Regulatory CLIA
Laboratory / All Lab test results / 1 year / Preference
Laboratory / All Annex Lab Tests QC / 2 years / Regulatory Medicare
Laboratory / All Annex Lab Test Logs / 7 years / Regulatory Medicare
Laboratory / All Satellite Lab Test Logs / 7 Years / Regulatory CLIA
Laboratory / Annex Lab Proficiency Testing / 2 years / Regulatory CLIA
Laboratory / Battle Ground Lab Proficiency Testing / 2 years / Regulatory CLIA
Laboratory / Salmon Creek Lab & Fishers Landing Lab Results and Quality Control records / 2 years / Regulatory CLIA
Department / Document Type / On Line / Quick Access Retrieval / Max Storage Time / Regulatory or Preference / Archived Retrieval SLA
Laboratory / Laboratory Instrument Calibrations / 2 years / Regulatory
Laboratory / Hematology Slides / 1 month / Regulatory CLIA
Laboratory / Gram Stains / 1 month / Regulatory CLIA
Medical Records / Patient charts / 7 years / Regulatory state
Medical Records / Consent to Treat - Face Sheet / 7 years / Regulatory, litigation
Medical Records / Flu shot records / Same as pt. charts / Regulatory state
Medical Records / Transcribed reports/dictation-Medword / 10 years / Preference
Medical Records / Day One records (Dr. Brice) / 10 years / Regulatory state
Pediatrics / Child abuse photos / Indefinite / Preference
Pediatrics / Phone logs / 10 years / Regulatory, litigation
Quality / Quality Council Packets / 10 Years / Preference
Quality / Policy and Procedures / Indefinite / Regulatory, litigation
Quality / Physician credentialing files-old / Indefinite / Preference
Quality / Employee Health to 1997 / 30 years / Regulatory, state
Quality / Risk Management Files / 10 years / Regulatory, litigation
Quality / WOC records / 10 years / Regulatory, litigation
Quality / Answering Service Logs / 10 years / Regulatory Litigation
Quality / Patient/Visitor Incident reports / 10 years / Regulatory, litigation
Radiology / Daily quality assurance logs for mammograms / 3 years / Regulatory, state
Radiology / Mammogram viewer logs / 5 years / Regulatory, state
Department / Document Type / On Line / Quick Access Retrieval / Max Storage Time / Regulatory or Preference / Archived Retrieval SLA
Radiology / Mammogram reports / Indefinite / Regulatory, state
Radiology / Equipment maintenance records / 2 years / Regulatory, state
Radiology / CT Quality Assurance Logs / 2 years / Regulatory, state
Radiology / Physician orders "The Blues" / 7 years / Regulatory, Medicare