Department: Ethics and Compliance policy description




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DEPARTMENT: Ethics and Compliance


POLICY DESCRIPTION: Records Management

PAGE: of 7

REPLACES POLICY DATED: 6/3/98, 2/1/99, 8/1/00, 8/1/03, 9/22/04, 1/1/06

EFFECTIVE DATE: July 1, 2009

REFERENCE NUMBER: EC.014

APPROVED BY: Ethics and Compliance Policy Committee




SCOPE: All Company-affiliated facilities including, but not limited to, hospitals, ambulatory surgery centers, home health agencies, physician practices, service centers, and all Corporate Departments, Divisions, Groups and Markets, for which the Company is responsible for business records.


PURPOSE: To establish the policy and procedures for the creation, use, maintenance, retention, preservation, and disposal of Company records.


POLICY:


  1. It is the Company’s policy to apply effective and cost efficient management techniques to maintain complete, accurate, and high quality records. Records are retained in accordance with all applicable laws and regulations and this policy.

  2. Records that have satisfied their required period of retention, and that are not subject to a Legal Hold, will be destroyed in an appropriate manner.

  3. Records will be managed responsibly, and retention schedules and destruction procedures and methods will be developed applicable to the Company’s records.

  4. All Company employees and agents are responsible for ensuring that all records are created, used, maintained, preserved, and destroyed in accordance with this Records Management policy.

  5. Vital and official records will be retained and protected to ensure the Company’s continued operations in the event of a natural or man-made disaster.

  6. Records containing confidential and proprietary information will be securely maintained, controlled and protected to prevent unauthorized access.

  7. All records generated and received by the Company are the property of the Company. No Company employee, by virtue of his or her position, has any personal or property right to such records even though he or she may have developed or compiled them.

  8. The unauthorized destruction, removal or use of such records is prohibited.

  9. No one may falsify or inappropriately alter information in any record or document.

  10. CEOs, Administrators, and Practice Managers shall designate an individual to be responsible for implementing and maintaining the Company’s records management programs at their facilities in accordance with this policy.

  11. A Records Management Committee will be established to review and approve all changes and revisions to the record retention schedules.

  12. Information pertaining to unauthorized destruction, removal or use of Company records or regarding falsifying or inappropriately altering information in a record or document should be reported to management, either directly or through the Ethics Line at 1-800-455-1996.


DEFINITIONS:

Records: A record is recorded information, regardless of medium or characteristic, that can be retrieved at any time. It includes all original documents, papers, letters, x-rays, cards, books, maps, photographs, blueprints, sound or video recordings, microfilm, magnetic tape, electronic media, and other information recording media, regardless of physical form or characteristic, that are generated and/or received in connection with transacting its business and is related to the Company’s legal obligations. If not stipulated otherwise, this is the record to which retention schedules apply.

Company business records include, but are not limited to, letterhead correspondence, legal opinions, real estate documents, directives and policies, official meeting minutes, personnel records, benefit programs, purchasing requisitions and invoices, accounts payable and receivable documents, tax documents, reimbursement documents, completed and signed forms, contracts, insurance documents, general ledgers, audit reports, and financial reports.


Medical or patient records include clinical data as well as patient demographic, clinical research and financial data.
Records can only be discarded when the specified retention period has expired, there is not an active Legal Hold prohibiting destruction, and a Certificate of Destruction form has been executed.
Non-Records: Non-records material includes duplicate copies of correspondence, duplicate copies of records used for short-term reference purposes, blank forms, stocks of publications, magazines, publications from professional organizations, newspapers, public telephone directories, and transitory messages used primarily for the informal communication of information. Transitory messages do not set policy, establish guidelines or procedures, certify a transaction, or become a receipt. Transitory messages may include, but are not limited to, e-mail messages with short-lived or no administrative value, voice mail, self-sticking notes, and telephone messages.
Non-records are maintained for as long as administratively needed, and the retention schedules do not apply. Non-records may be discarded when the business use has terminated, unless there is a Legal Hold in place prohibiting such destruction.
Discretion should be used in determining whether to generate or retain transitory messages in the nature of notes of unofficial meetings, telephone conversations, or other personal notes. If generated, such records should be routinely discarded when they are no longer useful. For example, when the informal record, such as an employee’s personal notes, is transferred to a more formal record, such as an incident report, the notes are no longer useful and should be discarded. Preliminary working papers and superseded drafts, particularly after subsequent versions are finalized, should be discarded. E-mail that contains no substantive data, such as invitations to lunch and responses to such, should be routinely discarded.

Vital Records: Vital records are records that are essential to the continued functioning or reconstitution of the Company or facility during and after an emergency and also preserve the rights of the Company or facility, its employees, customers, shareholders, and other constituent groups.



E-Mail Communications: E-mail communications, messages and documents transmitted by e-mail are similar to paper documents. They may be considered business records and are subject to this policy. To determine whether an e-mail message must be retained and for how long, think of it like a paper memo or document. If you would retain a memo due to its content, then you are required to retain an e-mail message of the same content for the same length of time.
The originator/sender of the e-mail message (or the recipient of a message if the sender is outside the Company) is the person responsible for retaining the message. E-mail messages may be retained in electronic form in the mailbox, or be printed and filed along with other documents related to the same topic or project. Unless a Legal Hold is in place prohibiting destruction, users may delete e-mail messages that they are not required by this policy to retain (such as non-record messages and transitory messages) and messages that are being retained in printed form.
Legal Hold: Legal Counsel may order a Legal Hold on certain records and electronic information, which must be preserved and not destroyed. When a Legal Hold is issued, the instructions in the Legal Hold take precedence over all policies including EC.014. Records and electronic information subject to a Legal Hold cannot be altered or destroyed without the prior consent of Legal Counsel.


PROCEDURES:
SECTION I. GENERAL
  1. Development of Records Retention Schedules





  1. All records will be maintained and retained in accordance with Federal and state laws and regulations. Minimum retention schedules are attached (Attachment D).




  1. Proposed changes, additions, or revisions to the record retention schedules will be submitted to Corporate Records Management for initial review. Corporate Records Management, in consultation with the Operations Section of the Legal Department, will research the legal, fiscal, administrative, and historical value of the records to determine the appropriate length of time the records will be maintained and provide an identifying code. The proposed revisions will be submitted to the Records Management Committee for review and approval. The approved changes will be incorporated into the Records Management Manuals and distributed to the designated Records Coordinators.




                1. Records Management Manuals

Corporate Records Management will develop Records Management Manuals that will incorporate the approved records retention schedules, which will be distributed to the individual identified pursuant to Policy Statement 10 and to Records Coordinators in each Corporate Department, Division, Market and Group.

      1. Records Coordinators


Corporate Departments, CEOs, Administrators, and Practice Managers shall designate an individual, using the attached appointment form (Attachment A), to serve as the Records Coordinator for their area. Send a copy of the form to Corporate Records Management. If the designated person departs, or when a new Records Coordinator assumes these duties, execute a new form and send it to Corporate Records Management. Coordinators will be responsible for implementing and maintaining records management programs. This responsibility should be assigned to a staff person with some existing records management skills or with the ability to learn various approaches necessary to develop and operate a records management program.

  1. Active/Inactive Records


Records are to be reviewed periodically to determine if they are active or inactive. Records that are no longer required as active will be reviewed and assessed for storage in the designated off-site storage facility. Duplicate, multiple and non-record materials are not to be sent to the designated off-site storage facility, but should be destroyed. Whenever possible, the official record is the one that will be retained according to the established retention.

SECTION II. RECORDS STORAGE
Records will be stored in accordance with the attached procedures (Attachment B).
SECTION III. RECORDS MANAGEMENT FORMS
Corporate Records Management will develop control forms relating to Company records to accomplish the following:

  1. Transferring records from active storage to inactive storage;

  2. Identifying, controlling, and maintaining records in storage;

  3. Retrieving and/or returning records from/to storage;

  4. Documenting the destruction of records and the deletion of records from the records inventory; and

  5. Monitoring the records management process.


SECTION IV. RECORDS DESTRUCTION


  1. Records that have satisfied their legal, fiscal, administrative, and archival requirements may be destroyed in accordance with the Records Retention Schedules.




  1. Records that cannot be destroyed include records to be retained in accordance with a Legal Hold or records with a permanent retention. In the event a Legal Hold is in place, records subject to the Legal Hold cannot be destroyed. After the Legal Hold has been terminated, the records may be destroyed in accordance with the Records Retention Schedules..




  1. Company records must be destroyed in a manner that ensures the confidentiality of the records and renders the information no longer recognizable as Company records. The approved methods to destroy Company records include, but are not limited to, recycling, shredding, burning, pulping, pulverizing, and magnetizing. A Certificate of Destruction form – 025 (Attachment C) must be approved and signed by the appropriate management staff prior to the destruction of records. Company records cannot be placed in trash receptacles unless the records are rendered no longer recognizable as a Company record.


SECTION V. TRAINING
Records Management personnel will periodically meet with the Records Coordinators to provide on-going training in the implementation of the Records Management Program. Training also will be provided on an individual basis for new individuals identified pursuant to Policy Statement 10, Records Coordinators and any individual or department that needs assistance.
SECTION VI. DIVESTITURE OR CLOSURE OF FACILITIES


  1. Divestiture of a Facility

In the event a facility or a line of business is sold, the Development Section of the Legal Department must ensure that sales documents will protect the Company’s right to access Company business and medical records and will stipulate the non-destruction of Company records as appropriate. Additionally, before divestiture, all facility electronic records must be backed up and transferred to Corporate Information Systems. Also, unless the sales documents specify otherwise, software documentation must be transferred to Corporate Information Systems. Patient medical records should remain with the facility to ensure continuity of patient care. Consistent with the overall retention policy, no records will be disposed of until the period of retention has expired for such records.


  1. Closure of a Facility

In the event a facility is closed, the Facility is responsible for notifying Corporate Records Management. The facility business records should be transferred to the nearest operating facility and Corporate Records Management must be notified of the new location of the records. If a facility is not available, the records should be transferred to Corporate Records Management and all facility electronic records must be backed up and transferred to Corporate Information Systems. Additionally, software documentation must be transferred to Corporate Information Systems. Patient medical records must be transferred to another facility or state archives in accordance with state requirements. Consistent with the overall retention policy, no records will be disposed of until the period of retention has expired for such records.
SECTION VII. RESPONSIBILITIES

  1. Records Management Committee


The Records Management Committee is to:

  1. Review and approve new retention schedules and revisions to current retention schedules and to authorize any changes to the Records Management procedures.




  1. The Records Management Committee will consist of representatives from Corporate Records Management, Ethics and Compliance, Legal, Tax, Finance, Internal Audit and Consulting Services, Health Information Management Services, Information Technology and Services, Reimbursement, and other representatives as appropriate. The Committee will meet at least annually.



B.Legal Department

  1. The Operations Section of the Legal Department is to serve as liaison with Corporate Records Management and Facility Records Coordinators to provide counsel regarding vital records designations and legal and statutory requirements for records retention and other pending legal matters; and




  1. The Development Section of the Legal Department is to ensure that the Company’s access to or ownership of Company records is appropriately protected in all divestitures of property or lines of business or facility closures.



SECTION VIII. EXCEPTIONS REPORTING MECHANISM
In the event that an employee believes another employee, a contractor or other individual is impermissibly destroying records or otherwise violating this policy, he/she should contact his/her supervisor or another member of management at the facility. If the employee is uncomfortable seeking resolution at the local level, he/she may contact the Ethics Line at 1-800-455-1996.

Attachment A


Letter of Appointment for Records Coordinator
Please Type or Print


Corporate Department/Facility Name COID



Address State Zip Code





Records Coordinator

Name Job Title/Position Telephone No.

( )

NOTES



  1. Corporate Department Heads, CEO’s, Administrators, and Practice Managers

shall designate an individual to be responsible for implementing and maintaining the Company’s records management program within their department or at their facilities

in accordance with the Records Management Policy, EC. 014.




  1. The designated individual must have access to the Company’s Outlook e-mail and Intranet.




  1. A common goal for all Coordinators is the effective creation, maintenance, retention, preservation, use, and proper disposal of Company records.




  1. When a person leaves the Records Coordinator position, the Corporate Department

Head, CEO, Administrator, or Practice Manager must ensure a replacement is named immediately and another Letter of Appointment Form is completed.


  1. Keep the original of this form locally and fax a copy to Corporate Records

Management in Nashville, TN at (615) 344-1300.

Name and Title of Appointing Official Signature Date



.
Attachment B

Records Storage


  1. Off-Site Storage Facilities

  1. The Company contracts with commercial off-site storage facilities to store, control, and protect inactive records. To the extent that they have access to Company records, the commercial off-site storage facilities must agree to maintain the confidentiality of the Company’s records.




  1. Off-site storage facilities are to be in secure locations that safeguard the records from the following:

  1. Ordinary hazards, such as fire, water, mildew, rodents, and insects;

  2. Man-made hazards, such as theft, accidental loss, sabotage, and commercial espionage;

  3. Disasters, such as fire, flood, earthquakes, hurricanes, wind, and explosions; and

  4. Unauthorized use, disclosure, and destruction.




  1. Off-site storage facilities are to provide proper vault storage with temperature and humidity controls for electronic, audio/video, and microfilm storage.




  1. Records storage containers are to be standard 12”x15”x10” boxes, unless the records require a special-sized box.




  1. Records series stored in the standard boxes must be adequately described and include the following information in order to facilitate their reference, review, and destruction:

  1. the inclusive dates;

  2. originating department and department number;

  3. type of media;

  4. retention code and title; and

  5. contact name and telephone number.




  1. Vital Records Storage

  1. Vital records are to be duplicated onto an appropriate media and the duplicate records stored in the designated off-site storage facilities, for reconstructive use in the event of a natural or man-made disaster.




  1. All facilities including, but not limited to, hospitals, ambulatory surgery centers, home health agencies, physician practices, and all Corporate Departments, Divisions, Markets and Groups are to maintain current lists of vital business records and forward copies of the lists to Corporate Records Management, which maintains a master list of vital business records for the Company. All facilities including, but not limited to, hospitals, ambulatory surgery centers, home health agencies, and physician practices are to maintain current lists of vital medical records.




  1. Electronic Records Storage

  1. The Company will select appropriate media and systems for storing Company records which meet the following retention requirements:

  1. Permit easy retrieval in a timely fashion;

  2. Facilitate distinction between record and non-record material; and

  3. Retain the records in a usable format until their authorized disposition date.




  1. The Company will consider the following factors before selecting a storage medium or converting from one medium to another:

  1. The approved retention of the record;

  2. The maintenance necessary to retain the records;

  3. The access time to retrieve stored records;

  4. The portability of the medium (selecting a medium that will run on equipment offered by multiple manufacturers) and the ability to transfer the information from one medium to another;

  5. The Company will avoid the use of floppy disks for the exclusive long-term storage of records with retention exceeding three years;

  6. The Company will ensure that all authorized users can identify and retrieve information stored on diskettes, removable disks, or tapes by establishing or adopting procedures for external labeling;

  7. The Company will establish a process to randomly check storage media based on industry standards to ensure that information is not lost due to changing technology or deterioration by converting storage media to provide compatibility with current hardware and software. Before conversion to a different medium, the Company will determine that the authorized disposition of the electronic records can be implemented after conversion;

  8. The Company will back up electronic records on a regular basis to safeguard against the loss of information due to equipment malfunctions or human error;

  9. The Company will not permit smoking or eating in electronic media storage libraries and test or evaluation areas which contain long-term records; and

  10. External labels for electronic recording media used to store long-term records will provide unique identification for each storage media, including: the name of the organizational unit responsible for the data; system title, including the version number of the application; special security requirements or restrictions on access, if any; and software in use at the time of creation.




  1. In addition the following information will be maintained for each media used to store long-term electronic records:

  1. file title;

  2. dates of creation;

  3. dates of coverage;

  4. the recording density;

  5. type of internal labels;

  6. volume serial number, if applicable;

  7. the number of tracks;

  8. character code/software dependency;

  9. information about block size; and

  10. sequence number, if the file is part of a multi-media set.




  1. The electronic media will be stored in an off-site location that is secure from unauthorized access and has a temperature, humidity, and static-controlled environment.




  1. Microfilm Storage

  1. The use of film media for records storage and retention purposes is to be selective and ensure cost effectiveness. Film media includes microfilm, microfiche, computer output microfiche/microfilm, or other similar types of media.




  1. To ensure authenticity of the documents filmed, the American National Standards Institute’s (ANSI) guidelines for microfilming documents will be followed.




  1. Microfilm storage for long-term records retention purposes will follow the ANSI requirements for packaging, handling, and temperature and humidity-controlled environment. The facility will be an off-site location with security from unauthorized access.


Instructions for Completing the Certificate of Records Destruction - 025



  1. Corporate Department/Facility Name: Enter the complete corporate department or facility name, whichever is appropriate.




  1. Department Number/COID: Enter the department number or COID, whichever is appropriate.




    1. Record Series Code and Record Series Title: Enter the approved record series title and the record series code. Please reference the Records Retention Schedules in the Records Management Policy EC.014 or either the Corporate Records Management Manual or the Facility Records Management Manual to provide authorized record series codes and titles.




    1. From and To Date: Enter the beginning and ending date of the box contents.




  1. Media: Enter the media format of the records being destroyed.




  1. Cubic Feet: Enter the cubic feet of records destroyed.




  1. Department Head/Senior Level Management: Either the Department Head or Senior Level Management must approve any records destruction by providing their name, title, a signature, and the date of approval.




  1. Records Coordinator: The designated Records Coordinator also should approve any records destruction for their corporate department or facility by providing their name, title, a signature, and the date of approval.




  1. Date of Destruction: Provide the date the records were destroyed.




  1. Total Cubic Feet: Provide the total cubic feet of records destroyed.




  1. Method of Destruction: Indicate the method of records destruction from the list provided. If the method is “Other”, describe it in the space provided.




  1. Records Destroyed By: If an outside company destroys the records, provide the company name, the name of the person performing the destruction, their title, their signature, and the date. If company staff destroys the records, provide the name of the person performing the destruction, their title, their signature and the date.




  1. Witness: Provide the name, title, and signature of the HCA representative witnessing the destruction and the date.


HCA

Certificate of Records Destruction – 025


1. Corporate Department/Facility Name

2. Department Number/COID

Please reference the Record Retention Schedules in either the Records Management Policy EC.014 or the Records Management Manuals to provide the authorized record series codes and titles.

3. Record Series Code

4. Record Series Title

5. From Date

6. To Date

7. Media

8. Cubic Feet

















































































































































Signatures indicate approval for destruction of the above records.

9. Department Head/Senior Level Management:
Name/Title:

Signature:

Date:



10. Records Coordinator:
Name/Title:

Signature:

Date:



The records described above were destroyed in the normal course of business pursuant to Records Management Policy EC.014. All parties involved in this destruction process agree to maintain the confidentiality of the documents destroyed.

11. Date of Destruction:





12. Total Cubic Feet:

13. Method of Destruction: Recycling Shredding



Pulping Pulverizing Magnetizing Burning

Other



14. Records Destroyed By:


Name/Title:

Signature:

Date:

15. Witness:


Name/Title:

Signature:

Date:




Retention Schedules

Available on Atlas on the Records Management or Ethics and Compliance Site.



5/2009


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