Transcription
Records Retention Schedule (1133-01)Approved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022Page 1 of 51
ContentsIntroduction. 30100 Governance . 50200 Legal. 70300 Risk Management . 80400 Communications . 110500 Education . 130600 Facilities & Asset Management . 140700 Finance . 170800 Human Resource Management . 210900 Information Management . 261000 Information Technology. 281100 Knowledge Management . 291200 Health Services . 301300 Laboratory Services . 361400 Program Services . 401500 Public Health . 411600 Research . 43Glossary of Records Management Terms . 45RRS Record of Amendment. 47Approved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022Page 2 of 51
IntroductionRecorded information is an element of any organization's infrastructure in that it supports and protects the organization’s mandatesand initiatives. It provides an audit trail of important business decisions and transactions in addition to demonstrating evidence ofcompliance with legal requirements.Good records management practices help to fulfill continuity of care functions and to identify and safeguard valuable, useful andlegally required records, regardless of format or media. Records are necessary to manage and comply with mandated statutoryrequirements. The Records Retention Schedule works to prevent the unnecessary accumulation and premature destruction ofrecords.The purpose of the AHS Records Retention Schedule is multi-faceted. Not only does it serve to identify those records of theorganization which have long term value, and hence must be maintained, but it also defines how long records must be maintainedand the final disposition of the records. Consistent application of the AHS Records Retention Schedule and compliance with AHSRecords Management Policy & Procedures assures that information is retained only as long as it is needed to meet legal, fiscal,operational and historical requirements and to reduce the chance for inconsistent or reckless disposal of records.The consequences for failure to meet legal and regulatory requirements to preserve documentation needed by an organization tomeet its mandates and initiatives range from loss of rights, time and money, to imposed fines and loss of public confidence.The attached Alberta Health Services Record Retention Schedule ensures that all corporate needs and requirements have been metwith respect to record retention. The retention periods set out in this document are mandatory periods for which AHS records mustbe retained. Both paper and electronic records must comply with this document.The AHS Records Retention Schedule is the definitive document that governs the following aspects of electronic, email and paperdocuments/records: how these records should be organized;how long these records must be retained; andwhen these records must be destroyed or archived.Approved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022Page 3 of 51
The Alberta Health Services Records Retention Schedule has been developed on a business functional model so that its structurecan remain stable during times of organizational change. As a result, information may fall in areas outside of the more familiardepartmental structure - E.g. Contracts are located within Legal – Contract Management, as they are legal documents, eventhough they will most likely be used and developed by other departments.Although there is a place for executive and board level minutes (see Governance – Board Administration, Governance – ExecutiveCommittee), there are no similar categories for operational level minutes and reports. These documents would fall under thefunctional records series for which they are operationally responsible.Relevant Policies & ProceduresRecords Management Policy # 1133Destruction Procedure # 1133-02Legal Hold Procedure # 1133-04Transitory Records Procedure # 1133-03Approved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022Page 4 of 51
0100 Governance[return to Table of Contents]Information related to the analysis, establishment and ongoing governance of programs and services. It covers the administration of the bodiesthat promulgate decisions that impact programs and services, and pertains to the process that supports decision-making. It includes identifyingand assembling information that is related to the organizations core business objectives in order to map out appropriate programs and servicesrelated to the effective management of AHS.RecordCodeFunctionSub Board Administration0130GovernanceExecutive CommitteesDescriptionNotesInformation related to thedocumentation of responsibilityfor operational andadministrative functions from anorganizational structureperspective, as well as thedelegation of authority attachedto positions and Conflict ofInterest declarations.Information related to thebusiness processes undertakenby the AHS Board to carry itsmandate, including relationshipswith government and thecommunity. It includes theappointment of members, itsresponsibilities, activities anddecisions. Includes bylaws andminutes.Information related to Executiveinteraction with other bodiesstructured for specific tasks.Committees include but are notlimited to: steering, subcommittees, work groups, taskforces, Board meetings, FacilityLeadership Council meetings,etc. Records include minutes,agendas, records of decision,reports and terms of reference.See functionalactivity or ProgramServices forDepartmental entionFinalDispositionCalendaryear end5 year tCalendaryear t, CanadianBusinessCorporationActApproved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022LegalReferencePage 5 of 51
RecordCodeFunctionSub Function0140GovernanceExternal y/ProceduresManagement.DescriptionInformation related to theinteraction betweenassociations, partnerships,memberships, governmentdepartments, advisory bodies,and other external organizationsand AHS. Records includecorrespondence, submission,reports and presentations,information that establishes theauthority of programs, services,or appointments throughanalysis, planning, development,approval or amendment oflegislation. Legislation includesstatutes, regulations, rules andorders.Information related to thedevelopment of strategic,operational plans, and businessplans, through the identificationof objectives and evaluatingalternative courses of action,analysis of emerging issues andtrends, and performanceindicators derived from thecontributions of stakeholdersand business units. It includesstrategic priorities andperformance goals that arereflected in the business planand reported in the annualreport.Information related to thedevelopment, acceptance, andreview of policies, procedures,standards, guidelines andprotocols that give broaddirection to the organization inconducting its operations and inproviding services.NotesSee also positionCalendaryear end5 yearsDestroyFiscal yearend11 yearsSelectiveRetention asdeterminedby theArchivistLimitations Actsection 3Supersededor obsolete30 yearsSelectiveRetention asdeterminedby S Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022LegalReferencePage 6 of 51
RecordCode0170FunctionGovernance0200 LegalSub FunctionReportingDescriptionNotesInformation related to theprovision of annual, ad hoc, ordesignated informationregarding corporate operations,specific initiatives or the financialstatus of the Region togoverning bodies or those withregulatory authority over theRegion. Includes auditedfinancial reports.Final disposition asdictated byreporting authorityClosureRuleFiscal yearendTotalRetention11 ion asdeterminedby theArchivist[return to Table of Contents]Information related to performing legal advisory services, the administration of legal instruments and assessing the legal implications of issues orinitiatives.RecordCodeFunctionSub Function0210LegalAdvisory0220LegalContract on related to discussingand providing expertise to legalmatters on behalf of theorganization. Includes analysis,opinions & regulatory advocacy.Information related to thecreation and final approval ofcontracts, agreements,memorandums of understanding,etc. including third partyagreements.Information related providingservices and support to theorganization before, during andafter a trial or hearing.NotesSignificant andunique contracts andagreements over 75, 000 must bekept permanently.File contractualagreements itionSupersededor obsolete11 yearsDestroyLimitations Actsection 3Contractended11yearsSelectiveRetention asdeterminedby theArchivistLitigationcompletedorabandoned11 yearsDestroyGovt of Alberta- NOTE:Significant anduniquecontracts andagreementsover 75, 000must be keptpermanently,Limitations Actsection 3Limitations Actsection 3Approved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022Page 7 of 51LegalReference
RecordCode0240FunctionLegalSub FunctionRights Management0300 Risk ManagementDescriptionNotesClosureRuleInformation related to thecreation, transfer andassignment of non-contractualrights. A right to ownership maybe asserted against any asset inwhich the organization has aninterest, such as intellectualproperty, copyright, patents,official marks and trademarks.All terms run toDecember 31 of theyear they are due toexpire.Supersededor obsoleteTotalRetentionFinalDisposition30 yearsDestroyLegalReferenceCopyright Actsection 6.1[return to Table of Contents]Information related to the identification, assessment and prioritization of risks followed by coordinated and economical application of resources tominimize and control the probability and/or impact of unfortunate events.RecordCodeFunctionSub function0310RiskManagementBusiness ContinuityPlanning0320RiskManagementIncident Reporting,Investigations - AdultsDescriptionInformation associated with theprocess of developing priorarrangements and proceduresthat enable an organization torespond to an event in such amanner that critical businessfunctions can continue.Reports and correspondence ofincidents and complaints byhealth system users. Includesinvestigation & reporting ofpatient safety incidents,information security breaches,physical security incidents,patient concerns and commentsand WHS reports relating toincidents involving staff injuryand Dangerous Work Refusalinvestigations.NotesClosure RuleTotalRetentionFinalDispositionS/O5 yearsDestroyInvestigationcompleted11 yearsDestroyApproved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022Page 8 of 51LegalReferenceLimitationsAct section 3,Alberta OHSAct Part 5,section 40(7)
RecordCodeFunctionSub Function0321RiskManagementIncident Reporting,Investigations - Minors0330RiskManagementInsurance - Claims0340RiskManagementInsurance - Policies0350RiskManagementQuality AssuranceDescriptionNotesClosure RuleTotalRetentionFinalDispositionReports and correspondence ofincidents and complaints byhealth system users. Includesinvestigation & reporting ofpatient safety incidents,information security breaches,physical security incidents, WHSreports relating to incidentsinvolving staff injury, patientconcerns and comments.Information associated withinsurance claims in response toreports of loss, theft, damage,repair estimates, investigations,vehicle accidents/loss reports,short term and long termdisability benefit claims.Information related to the takingout of premiums to cover loss orliability. 'Information related toinsurance coverage, bonds andbonding, assets and propertyvaluations, and other insurancematters. Includes insurancepolicies and certificates,employee benefit plans.Information related tothe planned or systematicactivity to study, assess orevaluate the provision of healthservices with a view to continuedimprovement of quality of healthcare & health services, and thelevel of skill, knowledge andcompetence of health serviceproviders. Includes: standardsand procedures required todeliver services and meetperformance criteria, qualityassurance committee andaccreditation activities.To be used only inthe investigation ofincidents involvingthe treatment &care of minors.Investigationcompleted; 10years past theage ofmajority 28years of age28 yearsof ageDestroyLimitationsAct section 3,Alberta OHSAct Part 5,section 40(7)Claimcompleted11 yearsDestroyLimitationsAct section 3Termination ofpolicy11 yearsDestroyLimitationsAct section 3Calendar yearend11 yearsSelectiveRetention asdeterminedby theArchivistLimitationsAct section 3Accreditationrecords andstandards mayhave permanentretention. QualityAssuranceCommittee recordsare protected fromdisclosure by theAlberta EvidenceAct (s. 9)Approved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022Page 9 of 51LegalReference
RecordCodeFunctionSub Function0360RiskManagementQuality Control0370RiskManagementDriver FilesDescriptionQuality control is related toactions taken to ensure thatprocedures intended to ensurethat a product or performedservice adheres to a defined setof quality criteria. QualityControl records may include:audits, sterilization &calibration records, qualitysurveys, inspections and testresults.Information related to driverapplication, employment historyfor 3 yrs preceding hire date,previous employer inquirydocumentation, driverauthorization form, valid driver’slicense, abstract summary,medical certificate,evaluation/operational trainingrecords, hours of servicerecords, TDG training certificatesissued under act, record of drivereducation courses, records of allmotor vehicle collisions requiringreport to peace officer,documentation of all trafficviolation convictions fromprovincial and federal legislationincluding photo radar and redlight camera violations.NotesClosure RuleTotalRetentionFinalDispositionCalendar yearend5 yearsDestroyTermination11 yearsDestroyApproved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022Page 10 of 51LegalReferenceLimitationsAct, AlbertaTraffic SafetyAct,CommercialVehicleCertificate &InsuranceRegulationAR 314/2002,Drivers Hoursof Service,Transportation ofDangerousGoods Act &Regulations
0400 Communications[return to Table of Contents]Information related to the development and dissemination of information regarding the organizations business and mandate using variousmethods and mediums.RecordCodeFunctionSub CommunicationDescriptionNotesClosure formation related to thedevelopment, review,approval and release ofinformation products andpublications relating to patientcare & clinical information.Includes content & design ofpatient education brochures& materials.Information related tocommunication plans andmaterials in consultation withstakeholders to achievecommunication goals, thedevelopment, approval anddistribution of deliveringmessages through variouscommunication vehicles, e.g.websites, broadcast media,etc.Information related to theorganization of events, tours,ceremonies and other publicvenues involving theorganizations and/orbusiness unit representation.Information related to thepreparation, submission ofand action on informationexchanged on specific issueswhere responses arerequired at the executivelevel. Including briefingnotes, speeches, lectures byofficials, requests for action.Final versions only.See CorporateCommunicationsfor corporatenewsletters,websites, etc.Supersededor obsolete11 yearsSelectiveRetention asdeterminedby theArchivistLimitationsAct section 3Final versions only.Supersededor obsolete3 yearsSelectiveRetention asdeterminedby theArchivistContact archivist asmaterials may havearchival value.Calendar yearend3 yearsSelectiveRetention asdeterminedby theArchivistCalendar yearend3 yearsSelectiveRetention asdeterminedby theArchivistApproved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022Page 11 of 51
RecordCodeFunctionSub Function0450CommunicationsInquiry onsMedia Monitoring0480CommunicationsVisual IdentityManagementDescriptionNotesClosure RuleTotalRetentionFinalDispositionInformation related to trackingand developing responses toinformal information requestsfrom stakeholders, otherlevels of government andinterest groups.Information related toprocesses associated withthe promotion and utilizationof the organizationsprograms/services andresource materials, socialmarketing initiatives andmanaging corporate profileand reputation. It includes thedevelopment ofadvertisements, displayadministration and thedistribution and circulation ofpromotional materials.Information related to thereview of media reports andinquiries and identification ofitems that require a response.Information related to theaccess and monitoring foruse of the visual identitymaterials.See InformationMgmt. - Access &Privacy for formalFOIP & HIAinformationrequests.See ClinicalCommunication forpatient / clinicalinformationmaterials.Calendar yearend3 yearsDestroyCalendar yearend3 yearsSelectiveRetention asdeterminedby theArchivistCalendar yearend3 yearsDestroyCalendar yearend5 yearsDestroySee Legal - RightsMgmt. forcopyright,trademarks etc.Approved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022Page 12 of 51LegalReferenceOperationalRequirements
0500 Education[return to Table of Contents]Information related to formal education programs offering accredited education such as nursing school programs. Also includes Staff Training andDevelopment.RecordCodeFunctionSub e f TrainingDescriptionOfficial record of a student'sgrades and courses.Documents may includeOfficial Transcripts, CertifiedCopies (Transcript) orunofficial copies issued bythe Region, student profilesand Certified Copies orunofficial copies of transcriptsfrom external organizationswhich have been obtained toconfirm prerequisiterequirements have been metfor enrollment.Documents related to coursesyllabus. Documentsmayinclude a summary or outlineof a specificcourse,prerequisite declaration (ifany) and materials required.Includes admission,enrollment & student records.Information related to thedevelopment of content usedfor learning purposes.Attendance & scheduling ofstaff training & developmentthough in-services, selfdevelopment orientation &competency assessments.NotesClosure RuleTotalRetentionFinalDispositionAcademicyear end50 lationFor formal DegreePrograms only.Academicyear end50 yearsS/RHistoricalRelevanceSee 0510 forformal certificates.Completion ortermination ofcourse ofstudy11 yearsDestroyPostSecondaryLearning Act- GeneralFacultiesCouncil,LimitationsAct section 3Supersededor obsolete5 yearsDestroyApproved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022LegalReferencePage 13 of 51
0600 Facilities & Asset Management[return to Table of Contents]Information that pertains to decisions that govern the operational administration of physical properties and equipment.RecordCodeFunctionSub inalDispositionLegalReferenceCanadaIncome TaxAct ss230,230.1 IncomeTax Regulation5800 andInformationCircular 7810RC0610Facilities & AssetManagementAssetManagement.Information related to theacquisition & management ofphysical assets, such asbuildings, land, majorequipment, vehicles,telecommunicationsequipment etc. Includessummaries of transactions,copies of invoices andreceipts and purchasesjournals, fixed assetinventories, depreciatedassets lists, surplusequipment, and write offs.Records also includegovernment and commerciallicenses and permits for useand operation of equipment,buildings, land, and permits,software licenses.Assetdisposed ofor fullydepreciated7 yearsSelectiveRetention asdeterminedby theArchivist0615Facilities & AssetManagementArchitecturalDrawings & Plans As BuiltRecords relating to all originalas issued drawings includingarchitectural, electrical,mechanical, civil/structural,and fire d:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022Page 14 of 51
RecordCodeFunctionSub FunctionDescriptionNotesClosureRuleMajor renovationsare defined as thoserequiring changes todrawing or requiringpermits.0620Facilities & AssetManagementCapital Builds &RenovationsInformation related to themanagement of the request,proposal review, approvaland implementationprocesses. Planning includesterms of reference, projectplan and request forproposals; GeneralAdministration includesprogress reports,correspondence and timeline;Financial includes budget orcost centers, invoices,insurance, leases andcontracts; designdevelopment bid documentsincludes specifications,drawings, and addendums;Contract administrationincludes changes orders,permits, certificates of finalcompletion and furniture andequipment. Renovationrequest, proposal review,approval and implementationprocesses. This includesrenovations required due tothe physical expansion oramalgamation of offices.0630Facilities & ion related to theutilities used such as naturalgas, electricity, steam, chilledwater, water/sewage.Records include historicaldata on consumption & 1 Year fromdate ofsubstantialcompletionof projectand/or aftergovernment audit, asrequired11 yearsSelectiveRetention asdeterminedby theArchivistLimitations Actsection 3,CanadaIncome TaxAct(230,230.1)Calendaryear end5 yearsSelectiveRetention asdeterminedby theArchivistCanadaIncome TaxAct ss230,230.1. IncomeTax Regulation5800 andInformationCircular 7810RCApproved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022Page 15 of 51
RecordCodeFunctionSub inalDispositionLegalReference0640Facilities & AssetManagementEquipment &Vehicle - Use andMaintenanceRecordsInformation related toinspection, repairs,maintenance and operationalmanuals for non-biomedicalequipment, ambulances andfleet vehicles. Also includesroutine equipmentmaintenance (e.g. dailyfunction checks), servicerecords.Calendaryear end5 yearsDestroyLicensing &AmbulanceMaintenanceRegulation s & AssetManagementEquipment - Biomedical Use andMaintenanceRecordsInformation related to thedesign, development, useand maintenance of biomedical equipment. Recordsinclude operating standards,modifications and requestsfor new equipment,evaluation or assessments ofexisting equipment,appraisals, maintenanceorders, investigational testing,logs, device validation/verification and summaryinformation. Includesinspection reports and FireExtinguishing System leakrecords.Equipmentobsolete/replaced11 yearsDestroyISO Standard13485 section4.2.5; CPSAStandard ations Actsection 30660Facilities & AssetManagementPhysical AccessControlThe materials and evidenceof activities related to theissuing and tracking ofphysical access controlmechanisms includingparking passes and cardkeys.Calendaryear end11 yearsDestroyLimitations Actsection 3Security surveillancetapes are treated astransitory recordsunless an incident iscaptured - See RiskManagement Incident Reporting,Investigations See1040 for NetworkArea Access(NAR’s)Approved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022Page 16 of 51
RecordCodeFunctionSub Function0670Facilities & AssetManagementProperty & WasteManagement0680Facilities & AssetManagementPropertyManagement0700 FinanceDescriptionNotesInformation related to themaintenance of physical workenvironments & manifestedhazardous waste disposal.Includes generalmaintenance activities suchas cleaning, repairs andmaintenance logs forbuildings and non-hazardouswaste management. Includesmanifests of transfers towaste treatment disposalservices.Information related to theoperation of physical assets,such as buildings, land, majorequipment,telecommunicationsequipment etc. Includesspace allocation & planning,summaries of transactions,copies of invoices andreceipts and purchasesjournals.Renovations notrequiring changes todrawings onLegalReferenceCalendaryear end3 yearsDestroyEnvironmentalProtections &EnhancementAct & WasteControlRegulationCalendaryear end11 yearsDestroyLimitations Actsection 3[return to Table of Contents]Information related to the administration of finance activities.RecordCode0710FunctionFinanceSub FunctionAccounting –General alDispositionInformation resulting from thefunction of managing theentries made in the generalledger. Includes financialaudits and audited financialstatements.The General Ledger orother book of finalentry containing thesummaries of the yearyear transactions. Thisis evidenced by a trialbalance of the wholeGeneral Ledger at theend of each fiscal year.Excludes informationheld in 0711.Fiscalyear endPermanentPermanentLegalReferenceCanadaIncome Tax Actxx 230, 230.1Income TaxRegulation5800 andInformationCircular 7810R3 Booksand RecordsRetention andDestructionApproved:AHS Records Retention ScheduleRecords and Information Management (RIM@ahs.ca)March 2022Page 17 of 51
RecordCodeFunctionSub Function0711FinanceAccounting –General Ledger –SupportingDocumentation0715FinanceAccounts Payable0720Fina
with respect to record retention. The retention periods set out in this document are mandatory periods for which AHS records must be retained. Both paper and electronic records must comply with this document. The AHS Records Retention Schedule is the definitive document that governs the following aspects of electronic, email and paper
