Lennox and Addington County General HospitalAdministration/Organization

RETENTION AND STORAGE OF RECORDSPR5-50

RETENTION AND STORAGE OF RECORDS

Approved by: / Administration / Effective Date: / October 3, 2011 / No. PR5-50
Issued by: / Administration / Review Date:
Department: / All / Replacing: / December 6, 2006 / Page 1 of 14

POLICY:

To ensure that the Lennox and Addington County General Hospital records are retained and stored in a reasonably secure manner and in accordance with legal requirements.

PROCEDURE:

  1. All records created, captured and managed within Lennox and Addington County General Hospital must be maintained in accordance with the applicable period set out in the Lennox and Addington County General Hospital Records Retention & Disposal Schedule set out in Appendix 1.
  1. Retention periods are based on applicable legal statutes, professional regulations, generally accepted industry practices and established Lennox and Addington County General Hospital policies.
  1. In the absence of any of the above, records are kept for as long as required by the purpose for which the information in the record was collected.
  1. Records shall not be kept for any longer than set out in the Retention & Disposal Schedule or as consented to by the patient unless for the purposes of managing legal risks with the approval of the CEO or if the Hospital receives notice of a court action, investigation, assessment, inspection, inquest, access request or other inquiry prior to the record’s destruction. All non-clinical records of an administrative nature that have not been addressed in the Schedule should be retained for a period of no more than two years.
  1. Multiple copies of a single record should not be kept as such a practice increases the chances of unauthorized use and disclosure of confidential information, places an undue financial burden on the Hospital and results in an inefficient use of space.
  1. During the retention period, records must be stored securely by providing adequate physical security, technological security and administrative controls to protect against unauthorized use and disclosure and the record being lost or stolen.
  1. Physical controls may include but are not limited to locked filing cabinets, restricted office access and a manned reception area to control physical access to a records storage area.
  1. Technological security may include but is not limited to intruder detection systems, password protecting documents and encryption. For more information, please refer to the Security of Personal Health Information Policy #PR5-40.
  1. Administrative controls may include but are not limited to prohibiting anyone without an LACGH badge from the records storage area, appointment of a staff member with responsibility for your area’s security, training on your security measures, confidentiality agreements for outside vendors and auditing of access to electronic records.
  1. The adequacy of any particular security measure is based on the sensitivity of the information and the risks to which it is exposed.
  1. Any storage facilities used for long-term storage of records should have adequate security and climate-control standards. If the facilities of an outside agency are used, these requirements should be specified in the contract. Staff may access the Corporate Privacy Officer to ensure these requirements are appropriately addressed in any storage agreement.
  1. All Lennox and Addington County General Hospital records stored electronically shall be subject to an automatic back-up for file recovery purposes to protect records from loss or damage.
  1. All Lennox and Addington County General Hospital records shall be disposed of in accordance with the Disposal – Personal Health Information Policy #PR5-60. In respect of all disposed of Hospital Health Records, the names of the patients to whom the records relate and the date and manner of destruction shall be recorded.

DEFINITIONS:

A “record” is any information received and/or created in the course of Hospital operations, in any form or media, including written, printed, photographic or electronic form, but excluding computer programs and other mechanisms that produce a record.

An “official custodian” has been assigned to each type of record in this policy. This identifies the department, unit or individual that has responsibility for the storage and maintenance of documents and other materials in accordance with this policy.

Lennox and Addington County General HospitalAdministration/Organization

RETENTION AND STORAGE OF RECORDSPR5-50

REFERENCES;

OHA Guidance Document #4: Information/Records Management and Establishing an Inventory of Records

Mount Sinai Hospital – Retention and Storage of Records Policy

Lennox and Addington County General HospitalAdministration/Organization

RETENTION AND STORAGE OF RECORDSPR5-50

Appendix 1
Corporate Records
Type of Record / Record Format / Retention
Period / Official Custodian / Statute/Regulation
Agreements/Contracts / Hard Copy / Permanent / Director of Quality / Limitations Act s. 4 and s. 15
Leases/Deeds / Hard Copy / Permanent / Office of the CEO / Limitations Act s. 4 and s. 15
Hospital Annual Report / Hard Copy / Permanent / Office of the CEO
Documents:
Documents of Incorporation / Hard Copy / Permanent / Office of the CEO / Corporations Act s. 300
Register of Directors / Hard Copy / Permanent / Office of the CEO / Corporations Act s. 300
Register of Members / Hard Copy / Ten Years / Office of the CEO / Corporations Act s. 300
Notices under the Corporations Information Act / Hard Copy / Permanent / Office of the CEO / Corporations Information Act
s. 5(2)
Policies / Electronic & Hard Copy / Permanent / Office of the CEO / Corporations Act s. 300
Limitations Act s. 4 and s. 15
Administrative By-Laws / Hard Copy / Permanent / Office of the CEO / Corporations Act s. 300
Medical Staff By-Laws / Hard Copy / Permanent / Office of the CEO / Corporations Act s. 300
Executive Correspondence / Hard Copy / Date of correspondence plus minimum 2 years up to 15 years. / Senior Management / Limitations Act s. 4 and s. 15
Insurance Policies / Hard Copy / 15 Years / Office of the CEO / Limitations Act s. 15
Minutes:
Board of Directors / Hard Copy / Permanent / Office of the CEO / Corporations Act s. 299(1) and s. 304
Income Tax Act Regulations
s. 5800(a)
Board Standing Committees / Hard Copy / Permanent / Office of the CEO / Corporations Act s. 299(1) and s. 304
Committees / Hard Copy / Permanent / Office of the CEO
Admin. Asst. / Corporations Act s. 299(1) and s. 304
Members’ Meetings / Hard Copy / Permanent / Office of the CEO / Corporations Act s. 299(1) and s. 304
Type of Record / Record Format / Retention
Period / Official Custodian / Statute/Regulation
Senior Management Team Minutes / Hard Copy / Permanent / Office of the CEO / Corporations Act s. 299(1) and s. 304
Quality and Risk Management
Litigation Files / Hard Copy / 7 Years / Director of Quality
Medical Advisory Committee:
Meeting Minutes / Hard Copy / Permanent / Office of the CEO / Corporations Act s. 299(1) and
s. 304
Subcommittee Minutes / Hard Copy / Permanent / Office of the CEO / Corporations Act s. 299(1) and
s. 304

Financial Records

Type of Record / Record Format / Retention
Period / Official Custodian / Statute/Regulation
General
Annual Financial Statements / Hard Copy / Permanent / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
General Journal / Hard Copy / Permanent / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Corporations Act s. 302
General Ledger / Hard Copy / Permanent / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Corporations Act s. 302
Source Documents (i.e. records integral to the creation of financial statements and tax returns) / Hard Copy / Six (6) years from the end of tax year (fiscal period) to which they relate / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Bank Reconciliation Statements / Hard Copy / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Bank Statements / Hard Copy / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Cancelled Cheques / Hard Copy / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Cheque Register / Hard Copy / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Type of Record / Record Format / Retention
Period / Official Custodian / Statute/Regulation
General Ledger Interface:
Accounts Payable Distribution & Receipts / Hard Copy / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Grant Accounts / Hard/Electronic
Copy / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Payroll:
Payroll Register / Hard/Electronic Copy / 7 Years / Payroll / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
T4/T4A Reports / Hard Copy/Disk / 7 Years / Payroll / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Time Sheets / Hard/Electronic Copy / 7 Years / Payroll / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Deduction Register / Electronic Copy / 7 Years / Payroll / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Patient Accounts:
Patient Ledger Card / Electronic / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Cash Receipts Register / Hard Copy / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Cash Receipts / Hard Copy / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Customer Invoices / Hard Copy / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Other Billing Invoices / Hard Copy / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Type of Record / Record Format / Retention
Period / Official Custodian / Statute/Regulation
Patient Accounts (Cont’d):
Bank Deposit Slips/Books / Hard Copy / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Safekeeping Envelopes / Hard Copy / Permanent / Inpatient Ward Clerk
Revenue Journals:
Accounts Receivable Revenue
Reports and Worksheets / Hard Copy / 10 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800; Health Insurance Act
Miscellaneous Accounting Records
Aging Analysis / Hard/Electronic Copy / 3 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Records supporting GST/HST rebate or refund / Hard/Electronic Copy / 6 Years / Finance / Statutory Requirement
Budget – Hospital Wide / Hard/Electronic Copy / Permanent / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Purchasing:
Capital Equipment Purchase Orders and original documents / Hard/Electronic Copy / Life of Equipment / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Non Stock Purchase Requisitions / Hard/Electronic Copy / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Return Goods Requisition / Hard/Electronic Copy / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Repair & Maintenance Requisitions / Hard/Electronic Copy / 7 Years / Finance / Income Tax Act s. 230(1)
Income Tax Act Regulations
s. 5800
Type of Record / Record Format / Retention
Period / Official Custodian / Statute/Regulation
Procurement Records
Related to the selection of supplier:
  • A copy of the procurement justification or the business case
  • Information regarding all supplier consultations, including any requests for information, undertaken in the development of the procurement business case and/or procurement documents;
  • Evidence that all required approvals were obtained;
  • Copies of all procurement documents used to qualify and select the supplier;
  • Where the procurement was conducted through a VOR arrangement, information regarding the second-stage selection process used to select the particular vendor of record;
  • Where the procurement was single or sole sourced, documented justification, applicable exemptions and associated approvals;
  • Copies of all advertisements of procurement documents;
  • Copies of all successful and unsuccessful responses, submissions, proposals and bids received in response to procurement documents, including the conflict-of-interest declaration and other attached forms;
  • Information regarding any issues that arose during the procurement process;
  • Information regarding all evaluations of submissions, proposals and bids received in response to procurement documents;
  • Information regarding all vendor debriefings including written documentation of the offer of vendor debriefing;
  • Copies of all award letters, notices and posted announcements;
  • Information regarding all changes to the terms and conditions of the Agreement, including any changes that resulted in an increase in the Agreement price;
  • Risk assessment information and recommendations, where applicable;
  • Information regarding all protests, disputes or supplier complaints regarding the procurement, including disputes with respect to the Agreement contents
/ Scanned Copy / 7 Years / Director of Quality / Broader Public Sector Procurement Directive, April 1 2010
Copies of the Agreement
See above for hard copy of agreement under “Corporate Records” / Scanned Copy in Contract Management System / 7 Years / Director of Quality / Broader Public Sector Procurement Directive, April 1 2010
Related to the management of the successful Vendor / resulting Agreement:
  • Information regarding the management of the supplier, including how the supplier’s performance was monitored and managed and, where applicable, mechanisms used to transfer knowledge from the supplier to organization staff;
  • Contractor screening decisions, where applicable;
  • Evidence of receipt of deliverables.
/ Scanned Copy / 7 years / Director of Quality / Broader Public Sector Procurement Directive, April 1 2010

Payroll/Human Resources Records

Type of Record / Record Format / Retention
Period / Official Custodian / Statute/Regulation
Employee Records:
Canada Pension Plan Contributions / Electronic Copy / Six years following the year for which they are kept / Payroll / Canada Pension Plan (Canada) ss. 24(2)
Designated Substance Exposure Records / Hard Copy / 40 Years / Occupational Health and Safety / Limitations Act s. 4 and s. 15
Ministry of Labour
Employees’ Earning Record Cards / Hard Copy/ Electronic Copy / Six years following the year for which they are kept / Payroll / Employment Insurance Act (Canada) ss. 87(3)
Employer’s Report of Injury/
Disease (Form 7) / Hard Copy / 40 Years / Occupational Health and Safety / Workplace Safety and Insurance Act s. 80
General Employment Records / Hard Copy / 3 years after creation date / Human Resources / Employment Standards Act
s. 15(5)
HOOPP Records Individual Contributions / Electronic Copy / 7 Years / Human Resources/
Payroll / Income Tax Act s. 230
Income Tax Act Regulations
s. 5800
Income Tax/T4 Forms / Hard Copy/Disk / 7 Years / Payroll / Income Tax Act s. 230
Income Tax Act Regulations
s. 5800
Occupational Health and Safety Records / Hard Copy / 40 Years / Occupational Health and Safety / Limitations Act s. 4 and s. 15
EHT Records/Billing Forms / Hard Copy / 7 Years / Payroll / Income Tax Act s. 230
Income Tax Act Regulations
s. 5800
Payroll Deduction Authoriza-tion Forms / Hard Copy / 7 Years / Human Resources/
Payroll / Income Tax Act s. 230
Income Tax Act Regulations
s. 5800
Payroll Journal Sheets / Hard/Electronic Copy / 7 Years / Payroll / Income Tax Act s. 230
Income Tax Act Regulations
s. 5800
Type of Record / Record Format / Retention
Period / Official Custodian / Statute/Regulation
Time Cards/Sheets / Hard/Electronic Copy / 7 Years / Payroll / Income Tax Act s. 230
Income Tax Act Regulations
s. 5800
EI Records / Hard Copy / 7 Years / Payroll / Employment Insurance Act
s. 87(3)
Union Dues Deduction Sheets / Hard/Electronic Copy / 7 Years / Payroll / Income Tax Act s. 230
Income Tax Act Regulations
s. 5800
WSIB Invoices / Hard Copy / 7 Years / Payroll / Income Tax Act s. 230
Income Tax Act Regulations
s. 5800
Minutes of Joint Health and Safety Committee / Electronic Copy / Current Year plus Minimum 6 years / Admin. Assistant / Limitations Act s. 4 and s. 15
Material Safety Data Sheet / Hard Copy / Date of Expiry plus Minimum 2 Years / Occupational Health & Safety / Limitations Act s. 4 and s. 15
Credentials/Medical Staff Files / Hard Copy / Permanent / Office of the CEO / Limitations Act s. 4 and s. 15

Quality and Risk Management Records

Type of Record / Record Format / Retention
Period / Official Custodian / Statute/Regulation
Quality and Risk Management Reports:
Patient/Visitor Incident Report / Hard/Electronic
Copy / 7 Years / Director of Quality / Corporate Policy
Accreditation Survey Recommendations / Hard/Electronic
Copy / 7-10 Years / Director of Quality / N/A
Patient Concerns / Hard/Electronic
Copy / Permanent / Office of the CEO / Corporate Policy
NRC Picker Patient Satisfaction Survey Results / Hard/Electronic
Copy / 7-10 Years / Director of Quality/Director of HR & Clinical Support Services / N/A
Disaster Plans / Intranet and Hard Copy / 10 Years / Director of Support Services/Project Manager / Corporate Policy

Patient Care Records and Other Materials

NOTE: RECEIPT OF A COURT ORDER OR NOTICE OF MOTION SUPERCEDES THIS RETENTION PERIOD. NO PATIENT RECORD MAY BE DESTROYED IF SUCH A DOCUMENT HAS BEEN RECEIVED.
Type of Record / Record Format / Retention
Period / Official Custodian / Statute/Regulation
Patient Register / Hard Copy and electronic / 50 Years / Health Records / Limitations Act s. 4 and s. 15
Patient Records / Paper, microfiche and electronic / 10 Years from last visit (or 10 years past the patient’s 18th birthday) whichever is longest / Health Records / Public Hospitals Act Regulation 965 20(3)
Diagnostic Images (excluding mammograms) / Electronic or Hard Copy / Adult (18 years and older)
At Least 5 Years After Day on Which the Image is Created.
Children (Less than 18 Years)
At Least 5 Years After the Patient’s 18th Birthday. / Medical Imaging / Public Hospitals Act
Regulation 965 20(4)(a)
Public Hospitals Act Regulation 965 20 (4)(b)
Diagnostic Images (Mammograms) / Electronic or Hard Copy / Adult (18 years and older)
At Least 10 Years After Day on Which the Image is Created.
Children (Less than 18 Years)
At Least 10 Years After the Patient’s 18th Birthday. / Medical Imaging / Public Hospitals Act
Regulation 965 20(5)(a)
Public Hospitals Act
Regulation 965 20(5)(b)

Patient Care Records and Other Materials

NOTE: RECEIPT OF A COURT ORDER OR NOTICE OF MOTION SUPERCEDES THIS RETENTION PERIOD. NO PATIENT RECORD MAY BE DESTROYED IF SUCH A DOCUMENT HAS BEEN RECEIVED.
Type of Record / Record Format / Retention
Period / Official Custodian / Statute/Regulation
Pharmacy Records:
Controlled Drug Records
Inpatient and Outpatient
Narcotic Records
Inpatient and Outpatient / Hard Copy / 2 Years / Pharmacy / Controlled Drugs and Substances Act Narcotic Control Regulations s. 63(b)
Inpatient and Outpatient Prescriptions / Hard Copy / 2 Years / Pharmacy / Drug and Pharmacies Regulation Act s. 156(2)
Record of Inpatient Dispensing / Electronic Copy / 2 Years / Pharmacy / Drug and Pharmacies Regulation Act s. 156(2)