Entity:

   I.              OBJECTIVE

Ohio University Heritage College of Osteopathic Medicine (OU-HCOM) Community Health Programs (CHP) and Appalachian Regional Health Institute (ARHI) Diabetes Education Center at OU-HCOM shall retain, and properly destroy records as follows (see policy).

   II.            DEFINITION

Records management: the application of systematic controls to records required in the operation of an organization.  Records are managed throughout their life cycle from creation or receipt through maintenance and use, storage and retrieval, to ultimate disposition or destruction.

Record:  a record is recorded information (regardless of physical format) that can be retrieved at any time.  Its various forms include all original documents, papers, letters, x-rays, cards, books, photographs, blueprints, sound or video recordings, microfilm, magnetic tape, electronic media, and any other information recording medium that are generated and /or received in connection with business or healthcare transactions and is related to OU-HCOM’s legal obligations.  Duplicate copies of original records used for short- or long-term reference purposes may also be considered records in a legal sense; therefore, they are subject to the same guidelines provided in this policy.

Non-record: its various forms include blank forms, magazines, and publications from professional organizations, newspapers, public phone directories, and transitory messages used primarily for informal communication of information.  Transitory messages do not set policy, establish guidelines or procedures certify a transaction or become a receipt.  These messages may include e-mail with short-lived or no administrative value, voice mail, self-sticking notes, and telephone messages.  Non-records are not subject to the retention schedule and are maintained for as long as administratively needed and may be discarded when their value has been exhausted.

Medical record:  all documents, regardless of physical format, that holds demographic and medical information about a patient.  Duplicate copies of any of these documents, in the same or different medium, may also be considered records.  Only the documents that are part of the designated record set are subject to the retention schedule.

Protected Health Information (PHI):  individually identifiable health information that is transmitted by electronic media transmitted or maintained in any other form or medium.  Individually identifiable health information (IIHI) is information that is a subset of health information.  IIHI includes demographic information collected from an individual, and is created or received by a health care provider, health plan, employer, or health care clearinghouse.  This information relates to the past, present, or future physical or mental health or condition of an individual and the provision of health care to an individual.  IIHI can identify the individual or there is a reasonable basis to believe that the information can be used to identify the individual.

Duplicate record:  a copy of the original or master record.  The retention schedule pertains only to the original document in its original format, or an official copy of the record if the original is no longer available.  A duplicate record should be retained only until the purpose for which the copy was obtained is served, at which time it should be destroyed appropriately.

Electronic record:  any combination of text, graphics, data, audio, pictorial, or other information representation in digital form that is created, modified, maintained, archived, retrieved, or distributed by a computer system.  Electronic technology is technology having electrical, digital, magnetic, wireless, optical, electromagnetic or similar capabilities.  Electronic records must be capable of generation in both human-readable and electronic form suitable for inspection, review, and copying.  Electronic records may be considered legal records, and are managed according to their content.

Retention period:  the period of time during which records must be maintained by an organization because the records have administrative, fiscal, legal, medical, or other value.  The records are eligible for disposal at the end of the retention period.

Record retention schedule:  a schedule of standard and/or legally required retention periods for each type of record, taking into account the administrative, fiscal, legal, medical, and historical value of those records.

Active records:  those records that still have sufficient administrative, fiscal, legal, medical, and/or historical value.

Inactive records:  those records which have lost some of their value or have been superseded by new records, but which have not reached the end of their specified retention period.  These are records that are usually referenced or accessed infrequently.

Disposal and/or destruction of records:  any action that prevents the recovery of information from the storage medium on which it is recorded including, but not limited to, shredding, pulping, incineration, erasure, and destruction of the hardware or medium used to store and/or recovers the information.

Storage medium:  any technology (including devices and materials) used to place, keep, and retrieve data on a long-term basis.  Some examples include hard disks, floppy disks, CD-ROMs, optical disks, and magnetic tape.

   III.           POLICY

   IV.          PROCEDURE

To be compliant with all applicable federal and state regulations, this policy will adhere to guidelines established by any pertinent regulatory or accrediting agencies as long as the guidelines meet or exceed federal or state regulations. Annual review of this policy will ensure continued compliance with federal, state, and any other applicable regulations.  OU-HCOM’s Director for Community Health Programs is responsible for overseeing and coordinating medical record compliance.

OU-HCOM is responsible for compliance with this policy as it pertains to records in their custody.  The Storage Company will be responsible for the physical safety and security of the records located on-site. OU-HCOM is responsible for identifying, labeling, and storing records which require retention, and transferring them to the appropriate storage site.  The Storage Company will obtain approval from OU-HCOM CHP before annual purging of documents, including identifying and destroying unnecessary duplicates; reviewing and destroying records which exceed the retention period. 

Upon receipt of notice regarding the initiation of an investigation, service of a subpoena, legal process, or audit, OU-HCOM or the Storage Company will promptly notify appropriate parties including University legal representative.  All tangible records (e.g. paper, film, etc.) will be designated “Secure File”, and transferred to the designated secure location.  Access to the “Secure file” will be restricted to prevent loss, tampering, or alteration of the records.  Access to electronic records will be coordinated with the appropriate individual or department to ensure the access or release is documented properly and in accordance with the OU-HCOM Policy as well as Federal, State Privacy Laws, Public Records Laws and Civil and Criminal Rules governing discovery during a litigation process.

Reproductions, duplicates or copies of records often have the same legal effect as the original or master record.   Copies may be subpoenaed and used in litigation even if the originals have been properly destroyed.  Copies of originals must be destroyed prior to or along with the originals as outlined in the retention schedule.

Any unauthorized access, use, reproduction, alteration, or destruction of OU-HCOM CHP records by associates or other persons must be reported immediately to the appropriate member of management.

A record in its original format is known as the record (master) copy.  An electronic record (master) copy may be created from the non-electronic record (master) copy as long as the appropriate standards are met.  The only formats that can be used for the new record (master) copy include microfiche, microfilm, and optical scanning. The electronic record then becomes the legal master record and the original records may be destroyed.  The electronic medium and electronic record-keeping system must provide access to the records throughout that record’s retention period.

RETENTION AND STORAGE

Medical records must be retained for the entire retention period as specified in the OU-HCOM Records Retention Schedule. During the retention period the records must be protected from alteration, tampering, loss, and physical damage.

On a periodic and scheduled basis, OU-HCOM should review the continued value and usefulness of the records.  Inactive records should be assessed for conversion to a format that would require less space, as with microfiche or electronic scanning.   

Tangible records must be boxed and the boxes labeled to permit efficient access and retrieval.  The label should contain, at a minimum, the originating department, the contact name and telephone number, the type of media, and the inclusive dates. The date the records are eligible for destruction should also be prominently displayed.

Any records involved in litigation or investigation are considered to be active records and should be stored on site and protected accordingly. Communication between OU-HCOM, the Storage Company, and University legal representative regarding these records is required.

Short-term and long-term storage facilities must meet appropriate environmental standards to minimize the chance of damage to the records from water, fire, theft, natural disasters, serious man-made accidents, and other potential threats. The storage facilities must provide proper storage with temperature and humidity controls to maintain the viability of the different storage media for the duration of the retention period.

Records that have satisfied their legal, fiscal, administrative, and archival requirements may be destroyed in accordance with the OU-HCOM Records Retention Schedule (and when appropriate, Federal Records Retention and Destruction Laws). On a periodic and scheduled basis, OU-HCOM should review the records under their custody to assess the continued value and usefulness of the information contained in the records. Destruction of certain records may occur prior to the end of the retention period if the record (master) copy has been transferred to an approved medium, such as microfilm or optical DVD.

Records that should not be destroyed include records involved in litigation or records with a permanent retention.  In the event of a lawsuit or government investigation, the applicable records that do not have permanent destruction cannot be destroyed until the lawsuit or investigation has been finalized.  Once the litigation/investigation has been finalized, the records may be destroyed in accordance with the OU-HCOM Records Retention Schedule.

Destruction is any action that prevents the recovery of information from the storage medium, regardless of physical format.  The method of destruction for a particular type of record must be appropriate to the medium.   Methods of destruction include, but are not limited to, shredding, pulping, pulverizing, magnetizing, encryption, burning, erasure, and destruction of the hardware or medium used to store and/or recover the information on the records.  Disposal of information systems equipment, including the irreversible removal of information and software, must be carried out in accordance with approved procedures.

OU-HCOM CHP records must be destroyed in a manner that maintains the confidentiality of the records and renders the information no longer retrievable or recognizable as OU-HCOM CHP records.  Destruction of records must be carried out by bonded destruction service that handles sensitive and confidential records.

Last updated: 08/06/2012