Personal Information Bank

Personal Information Bank

Oak Valley Health is required under the Freedom of Information and Protection of Privacy Act (“FIPPA”) to produce an index of Personal Information Banks (PIB) – a description of the collections of personal information (recorded information about an identifiable individual) maintained to support the Hospital’s programs and activities, where such collections are organized and retrievable by an individual’s name or another identifier.

The Personal Information Bank includes the following:

  • The title and type of the class of records
  • The statute authorizing the collection of personal information
  • The location of this class of records
  • The format of this class of records
  • A description of the type of information that is maintained in this class of records
  • The uses and users of the personal information maintained in this class of records
  • A description of the types of individuals whose information is maintained in this class of records
  • The retention and disposal (how long the information is kept)

The PIB can help individuals formulate clear and defined requests. It is important to remember that while these tools can be useful in defining the types of records held by Oak Valley Health, the records of the Hospital are subject to FIPPA and may be subject to exemptions and/or exclusions that could limit the amount of information disclosed.

Childbirth and Children's Services

Birth Logs

Purpose of the Record (Legal Authority)

CMTE

Description

A book containing information about all births at Markham Stouffville Hospital 

Location

Labour & Delivery

Record Format

Paper

Type of Personal Information Maintained

Personal information, labour/birth details, weight and method of delivery of baby, care team

Uses

Data collection

Users

Labour & Delivery

Individuals in Bank

Every patient born in MSH (Still, Live, Products of Conception)

Retention and Disposal

Permanent

Community Resources 

Volunteer Record - Active & Inactive Volunteers

Purpose of the Record (Legal Authority)

Hospital record retention policy

Description

Records relating to volunteer personal information and schedules.

Location

Community and Volunteer Resources

Record Format

Paper and Electronic

Type of Personal Information Maintained

Contact information, date of birth, emergency contact details, health information

Uses

Volunteer Management

Users

Staff, Managers

Individuals in Bank

Community and Volunteer Resources Employees

Retention and Disposal

Seven (7) years after resignation or termination date          

Permanent (print copy)

Volunteer Applications

Purpose of the Record (Legal Authority)

Hospital record retention policy

Description

Records relating to volunteer personal information.

Location

Community and Volunteer Resources

Record Format

Paper and Electronic

Type of Personal Information Maintained

Contact information, date of birth, emergency contact details, health information

Uses

Volunteer Management

Users

Community and Volunteer Resources staff

Individuals in Bank

Community and Volunteer Resources Employees

Retention and Disposal

One (1) year (print copy)

Co-op High School Student Records

Purpose of the Record (Legal Authority)

Hospital record retention policy

Description

Records relating to students personal information and schedules.

Location

Community and Volunteer Resources

Record Format

Paper and Electronic

Type of Personal Information Maintained

Contact information, date of birth, emergency contact details, health information

Uses

Volunteer Management

Users

Staff, Managers

Individuals in Bank

Community and Volunteer Resources Employees

Retention and Disposal

Seven (7) years from termination

Permanent (print copy)

Community Living York South Records

Purpose of the Record (Legal Authority)

Hospital record retention policy, Community Living policy

Description

Records relating to staff personal information and schedules.

Location

Community and Volunteer Resources

Record Format

Paper and Electronic

Type of Personal Information Maintained

Contact information, date of birth, performance information, schedules

Uses

Employment Management

Users

Staff, Managers

Individuals in Bank

Community and Volunteer Resources Employees

Retention and Disposal

Seven (7) years from termination

Permanent (print copy)

Staff Schedules

Purpose of the Record (Legal Authority)

Hospital record retention policy

Description

Records relating to staff personal information and schedules.

Location

Community and Volunteer Resources

Record Format

Paper and Electronic

Type of Personal Information Maintained

Contact information, date of birth, performance information, schedules

Uses

Employment Management

Users

Staff, Managers

Individuals in Bank

Community and Volunteer Resources Employees

Retention and Disposal

Seven (7) years

Corporate Administrative Records

Professional Staff Credentialing

Purpose of the Record (Legal Authority)

Public Hospitals Act R.S.O 1990 c. P. 40, Hospital By-laws

Description

Records relating to the recruitment and credentialing of professional staff

Location

Medical Administration

Record Format

Paper and Electronic

Type of Personal Information Maintained

Contact information, education and employment history, health information, personal information as required

Uses

Credentialing and appointment of professional staff

Users

Medical Administration, Chief of Staff

Individuals in Bank

Doctors, Dentists, Midwives

Retention and Disposal

End of the last appointment year plus 15 years

Diagnostic Imaging, Cardio Respiratory, and Electrodiagnostic General Reports

Radiopharmaceutical Dose Dispensing Records

Purpose of the Record (Legal Authority)

Canadian Nuclear Safety Commission (CNSC)

Description

Record of radiopharmaceutical administration

Location

Nuclear Medicine

Record Format

Paper

Type of Personal Information Maintained

Patient name, medical record number

Uses

License compliance

Users

Medical Radiation Technologists

Individuals in Bank

Patients

Retention and Disposal

One (1) year after the expiry of the CNSC license in effect on date of activity; as required by General Nuclear Safety and Control Regulations (GNSC (28(1))

Finance

Year End Audit Working File

Purpose of the Record (Legal Authority)

Income Tax Act

Description

Only applies if there is an audit request of sampling for employee compensation or patient revenue

Location

Finance

Record Format

Electronic

Type of Personal Information Maintained

Employee payroll, patient revenue record

Uses

External audit

Users

External Auditor

Individuals in Bank

Dependent on sample selected

Retention and Disposal

Seven (7) years

Cheque Register

Purpose of the Record (Legal Authority)

Income Tax Act

Description

Record of all cheque transactions during an accounting period

Location

Finance

Record Format

Electronic

Type of Personal Information Maintained

Employee information 

Uses

Balance to Plexxus posting

Users

Accounting

Individuals in Bank

Employees

Retention and Disposal

Seven (7) years

Bank Deposit Slips

Purpose of the Record (Legal Authority)

Income Tax Act

Description

Form that accompanies a cheque or cash payment 

Location

Finance

Record Format

Electronic

Type of Personal Information Maintained

Employee information 

Uses

Balance to GL and Bank Statements

Users

Accounting

Individuals in Bank

Employees

Retention and Disposal

Seven (7) years

Bank Statements

Purpose of the Record (Legal Authority)

Income Tax Act

Description

An official summary of financial transactions occurring within a given period for each bank account held by a business with a financial institution

Location

Finance

Record Format

Electronic

Type of Personal Information Maintained

Employee information 

Uses

Balance to GL and Bank Statements

Users

Accounting

Individuals in Bank

Employees

Retention and Disposal

Seven (7) years

Bank Reconciliations

Purpose of the Record (Legal Authority)

Income Tax Act

Description

Summary of bank statements matched with transactions that are recorded during an accounting period

Location

Finance

Record Format

Electronic

Type of Personal Information Maintained

Employee information 

Uses

Balance to GL and Bank Statements

Users

Accounting

Individuals in Bank

Employees

Retention and Disposal

Seven (7) years

Payroll Register

Purpose of the Record (Legal Authority)

Income Tax Act

Description

Total earnings of all employees during a bi-weekly payroll period

Location

Meditech EMR system

Record Format

Electronic

Type of Personal Information Maintained

Employee Payroll

Uses

Balance to GL and Bank Statements

Users

Payroll, Accounting

Individuals in Bank

Employees

Retention and Disposal

Seven (7) years

Timecards

Purpose of the Record (Legal Authority)

Income Tax Act

Description

Record of an employee's starting and quitting times

Location

Meditech EMR system

Record Format

Electronic

Type of Personal Information Maintained

Employee Payroll

Uses

Support Employee Manager approved hours

Users

Payroll

Individuals in Bank

Employees

Retention and Disposal

Seven (7) years

Deduction Register

Purpose of the Record (Legal Authority)

Income Tax Act

Description

Record of all payroll deductions made during a bi-weekly payroll period

Location

Meditech EMR system

Record Format

Electronic

Type of Personal Information Maintained

Employee Payroll

Uses

Balance to GL and Remittances

Users

Payroll, Accounting

Individuals in Bank

Employees

Retention and Disposal

7 years

Employee Earning Record

Purpose of the Record (Legal Authority)

Employee Insurance Act (Canada), ss.87(3)

Description

Report that details how much employees are paid during the year

Location

Meditech EMR system

Record Format

Electronic

Type of Personal Information Maintained

Employee Payroll

Uses

Balance to GL, Budgets and Remittances

Users

Payroll

Individuals in Bank

Employees

Retention and Disposal

Seven (7) years

Healthcare of Ontario Pension Plan (HOOPP) Records - Individual Employee Deductions

Purpose of the Record (Legal Authority)

Ontario Pension Benefit Act

Description

Summary of deductions made by HOOPP for each employee

Location

Meditech EMR system

Record Format

Electronic

Type of Personal Information Maintained

Employee/Employer Contributions

Uses

Remittances, Balance Sheet Reconcilliation, Budgets, HOOPP MDC Submission

Users

Payroll, Accounting

Individuals in Bank

Employees

Retention and Disposal

Seven (7) years

Customer Invoices

Purpose of the Record (Legal Authority)

Income Tax Act

Description

Invoices issued to patients for additional expenses incurred during hospital stay (i.e. medical equipment)

Location

Meditech EMR system

Record Format

Electronic

Type of Personal Information Maintained

Demographic (name, account number, address, personal health information)

Uses

Patient payments

Users

Revenue Cycle Group (as needed)

Individuals in Bank

Patients

Retention and Disposal

Seven (7) years

Accounts Receivable Revenue Reports and Worksheets

Purpose of the Record (Legal Authority)

Income Tax Act

Description

Reports that are generated on a monthly basis to determine the hospital’s revenue 

Location

Finance, Meditech EMR system

Record Format

Electronic

Type of Personal Information Maintained

Demographic (name, account number, address, personal health information)

Uses

Insurance submissions, Ministry of Health submissions, monthly/annual reviews for AR days and dollars

Users

Revenue Cycle Group (as needed)

Individuals in Bank

Patients

Retention and Disposal

Seven (7) years

OHIP Billing Information

Purpose of the Record (Legal Authority)

Health Insurance Act, s.37.1

Description

Records relating to claims submitted to the Ministry of Health in respect of treatment and services provided to patients under the Ontario Health Insurance Plan (OHIP)

Location

Finance, Meditech EMR system

Record Format

Electronic

Type of Personal Information Maintained

Demographic (CSID, personal health information)

Uses

Submission, Rejection retention for records

Users

Revenue Cycle Group (as needed)

Individuals in Bank

Patients

Retention and Disposal

Seven (7) years

Annual Adjusting Journal Entries

Purpose of the Record (Legal Authority)

Income Tax Act, s.230

Description

Some payroll liability adjustments

Location

Finance, Off-site storage

Record Format

Electronic

Type of Personal Information Maintained

Leadership bonus and termination package

Uses

For annual payroll liability accrual

Users

Accounting Team, External Auditor (where applicable)

Individuals in Bank

Employees

Retention and Disposal

Seven (7) years

Charity Return

Purpose of the Record (Legal Authority)

Statutory Requirement

Description

Required document that contains board of director information (name, address, date of birth, etc.)

Location

Finance

Record Format

Electronic

Type of Personal Information Maintained

Board of director information (name, address, date of birth, etc.)

Uses

For annual charity return submission to CRA

Users

Finance, Canada Revenue Agency

Individuals in Bank

Board of Directors

Retention and Disposal

Date of record ± 10 years

Health Records

Master Patient Index

Purpose of the Record (Legal Authority)

Public Hospitals Act. Reg. 965

Description

Patient database used to maintain accurate medical data of all patients.

Location

Health Information Management, Meditech EMR System

Record Format

Microfiche, Paper and Electronic

Type of Personal Information Maintained

Personal Health Information, Personal Information

Uses

Patient care, evaluation of quality of care and service provision

Users

Care providers

Individuals in Bank

Patients

Retention and Disposal

Permanent

Admission Discharge Transfer List

Purpose of the Record (Legal Authority)

Public Hospitals Act. Reg. 965

Description

Records relating to the admission, discharge and transfer information of patients.

Location

Health Information Management, Meditech EMR System

Record Format

Paper and Electronic

Type of Personal Information Maintained

Personal Health Information, Personal Information

Uses

Patient care, bed management

Users

Care providers

Individuals in Bank

Patients

Retention and Disposal

Permanent

Health Record (includes imaging, examination of the breast)

Purpose of the Record (Legal Authority)

Public Hospitals Act. Reg. 965

Description

Variety of records relating to patient care

Location

Health Information Management, Meditech EMR System

Record Format

Paper and Electronic

Type of Personal Information Maintained

Patient name, date of birth, health card number, medical record number, account number, medical condition and diagnostic information, test results, medications, records relating to any surgery or medical procedures

Uses

Patient care, evaluation of quality of care and service provision, research approved by Research Ethics Board

Users

Care providers, employees responsible for meeting provincial reporting requirements, researchers approved by Research Ethics Board

Individuals in Bank

Patients

Retention and Disposal

10 years after discharge/death, 10 years after patients 18th birthday

ECG’s

Purpose of the Record (Legal Authority)

Public Hospitals Act. Reg. 965

Description

Medical images of patients

Location

Health Information Management, Meditech EMR System

Record Format

Electronic

Type of Personal Information Maintained

Patient name, date of birth, health card number, medical record number, account number, ECG strip(s)

Uses

Diagnosis and care and treatment of patient

Users

Care providers

Individuals in Bank

Patients

Retention and Disposal

10 years after discharge/death, 10 years after patients 18th birthday

Diagnostic Imaging and Cardio Respiratory Records of a Patient (excluding Imaging Exam of the Breast)

Purpose of the Record (Legal Authority)

Public Hospitals Act. Reg. 965, See Policy 090.700.090 – Medical Records Retention

Description

Medical images of patients

Location

Health Information Management, Meditech EMR System

Record Format

Electronic

Type of Personal Information Maintained

Patient name, date of birth, health card number, medical record number, account number, diagnostic images, interpreting radiologist name, referring Most Responsible Provider (MRP) name, interpretation of images in the form of a report/note

Uses

Diagnosis and care and treatment of patient

Users

Care providers

Individuals in Bank

Patients

Retention and Disposal

Five (5) years after the day on which the record is created. 10 years after the patients 18th birthday

Human Resources

Employee Record

Purpose of the Record (Legal Authority)

Employment Standards Act, Oak Valley Health Policy

Description

Records related to employment of individuals at Oak Valley Health, including attendance, scheduling, employment history, performance management, training information, employment contracts, job competition and recruitment records.

Location

Human Resources

Record Format

Paper and Electronic

Type of Personal Information Maintained

Contact information, employee number, emergency contact information, individual resumes, employment history including wage information, education, attendance and leave records, performance evaluations, disciplinary records, benefit history, beneficiary information

Uses

Document employment history

Users

Human Resources, Department Leaders

Individuals in Bank

Employees (permanent and contract)

Retention and Disposal

Three (3) years after termination/if employee under 18, three (3) years after 18th birthday

Seven (7) years from termination

Timecards/Records

Purpose of the Record (Legal Authority)

Canada Labour Code

Description

Record of an employee's starting and quitting times

Location

Meditech

Record Format

Electronic

Type of Personal Information Maintained

Name, Mnemonic, Attendance

Uses

Calculation of employee payroll

Users

Unit Clerks, Team Leads

Individuals in Bank

Employees

Retention and Disposal

Three (3) years after work is performed or employee terminates

Employee Earning Record

Purpose of the Record (Legal Authority)

Canada Labour Code, Canada Revenue Agency

Description

Report that details how much employees are paid during the year

Location

Meditech

Record Format

Electronic

Type of Personal Information Maintained

Employee Bi-weekly paid hours

Uses

Calculation of employee payroll

Users

Payroll, Accounting

Individuals in Bank

Employees

Retention and Disposal

Three to seven (3-7) years after work is complete depending on earnings paid (e.g. vacation paid is five (5) years retention and gross earnings is seven (7) years retention)

Payroll, Deduction, Authorization Records

Purpose of the Record (Legal Authority)

Canada Revenue Agency

Description

Summary of employee earnings, deductions made and any funds that are withheld

Location

Meditech

Record Format

Electronic

Type of Personal Information Maintained

Employee Payroll

Uses

Employee withholding for source deductions of gross pay

Users

Payroll, Accounting

Individuals in Bank

Employees

Retention and Disposal

Seven (7) years from termination or revocation of authorization

HOOPP Records, not including individual employee deductions

Purpose of the Record (Legal Authority)

Canada Revenue Agency, Oak Valley Health Policy, HOOPP Policy

Description

Records related to benefit plans start and end date, employee's agreement

Location

Human Resources and Payroll

Record Format

Paper and Electronic

Type of Personal Information Maintained

HOOPP enrollment form, opt in/out agreement. May also include records relating to insurance or benefit carriers' policies and directives. Individual employee deduction - Meditech and Payroll.

Uses

Administer HOOPP plan setup, leave start/end date. Payroll - remittances and deductions.

Users

Human Resources, Payroll, HOOPP

Individuals in Bank

All eligible employees

Retention and Disposal

77 years from termination as it relates to gross earning deductions                                    

NOTE: HOOPP records affecting a plan member’s calculation of benefits, pension adjustments, pension adjustment reversals, past service are kept indefinitely

Income tax–copies of T-4Slips

Purpose of the Record (Legal Authority)

Canada Revenue Agency

Description

Tax document that summarizes annual employment earnings as well as any deductions

Location

Meditech

Record Format

Electronic

Type of Personal Information Maintained

Staff name/address/income, employee/employer source deductions and taxable benefits, HOOPP Pension contribution, pension adjustments and hospital business number

Uses

CRA reporting and staff distribution

Users

Payroll Team

Individuals in Bank

Employees

Retention and Disposal

Seven (7) years (six (6) years from the end of the taxation year to which they relate)

Union Dues Deduction Records

Purpose of the Record (Legal Authority)

Canada Revenue Agency

Description

Records related to union dues paid by unionized employees

Location

Meditech

Record Format

Electronic

Type of Personal Information Maintained

Employee info and bi-weekly deductions

Uses

Union Remittance, T4 info.

Users

Payroll Team

Individuals in Bank

Unionized employees

Retention and Disposal

Seven (7) years except where collective agreement states otherwise

Employment Insurance Records

Purpose of the Record (Legal Authority)

Canada Revenue Agency

Description

Record the provides information on employment insurance deductions and employment bi-weekly eligible remuneration for Record of Employment submission to Service Canada

Location

Meditech

Record Format

Electronic

Type of Personal Information Maintained

Staff name/address/bi-week insurable earnings and hours/leave and/termination reason/first and last day worked, employee/employer source deductions and hospital business number

Uses

Service Canada Remittance, ROE Issuance

Users

Payroll

Individuals in Bank

Employees

Retention and Disposal

Seven (7) years from date of Certification of Inspection by EI Commission

Employment Contracts

Purpose of the Record (Legal Authority)

Oak Valley Health Policy

Description

Employment contract between individual and the hospital

Location

Human Resources

Record Format

Paper and Electronic

Type of Personal Information Maintained

Employee employment contract, contact information, job offer, salary and benefit information.

Uses

HR management

Users

Human Resources 

Individuals in Bank

Employees (permanent and contract)

Retention and Disposal

Seven (7) years from termination date

Employee Performance Appraisals

Purpose of the Record (Legal Authority)

Oak Valley Health Policy

Description

Records related to the performance management program for hospital employees. 

Location

Human Resources, departmental leader files

Record Format

Paper and Electronic

Type of Personal Information Maintained

Career development planning, interim and annual/bi-annual reviews. Records includes accountabilities, goals, measures, timelines, progress reports.

Uses

Personal and professional development of employees

Users

Human Resources, Department Leaders

Individuals in Bank

Employees (permanent and contract)

Retention and Disposal

Seven (7) years from termination date

Benefit Records

Purpose of the Record (Legal Authority)

Oak Valley Health Policy

Description

Records related to benefit plans for eligible hospital employees, retirees and/or their families. Also includes benefits billing records

Location

Human Resources

Record Format

Paper and Electronic

Type of Personal Information Maintained

Group life insurance, ADD, long and short-term disability coverage, extended health and dental benefits. May also include records relating to insurance or benefit carriers' policies and directives, deducting benefits coverage from the hospital's payroll, and types of benefit coverage.  May also include benefits coverage policies/contracts, statistical reports and supporting correspondence. 

Uses

Administer benefits plans

Users

Human Resources, Payroll, Benefits Carrier

Individuals in Bank

Plan members, Spouse and/or Dependents

Retention and Disposal

Voluntary Group Life application – seven (7) years from date of termination

Benefits enrollment form- seven (7) years from date of termination

HOOPP enrollment form- seven (7) years from date of termination

STD/LTD Records- seven (7) years from date of termination

Beneficiary Designation Forms

Purpose of the Record (Legal Authority)

Oak Valley Health Policy

Description

Beneficiary information

Location

Human Resources

Record Format

Paper and Electronic

Type of Personal Information Maintained

Employee ID, name, contact information, Date of Birth, sex, marital status, beneficiary information.

Uses

Administer benefits plans

Users

Human Resources

Individuals in Bank

Plan members, spouse and/or dependents

Retention and Disposal

Seven (7) years from termination date

Post-termination Benefit Records

Purpose of the Record (Legal Authority)

Oak Valley Health Policy

Description

Health & Dental records. Beneficiary information

Location

Human Resources

Record Format

Paper and Electronic

Type of Personal Information Maintained

Employee name, address, phone number, life policy amount, beneficiary information, bank information, email address, salary continuance benefits and compensation information

Uses

Administer retiree benefits life plan, salary continuance contract

Users

Human Resources, Payroll, Benefits Carrier

Individuals in Bank

Plan members and their beneficiary, Terminated employees

Retention and Disposal

Until death of the employee Retirees with life insurance – enrolment and beneficiary form retained permanently
post retirees' health and dental records will terminate according to the plan (either 65, or 70)

Staff Schedules

Purpose of the Record (Legal Authority)

Oak Valley Health Policy

Description

Records related to staff scheduling that documents hours of work, overtime hours, shift schedules, vacation time, statutory holidays, sign-in sheets, sick leave.

Location

Department Leaders

Record Format

Paper and Electronic

Type of Personal Information Maintained

Hours of work, leaves of absence, overtime, statutory holidays, sick time taken, vacation days, attendance

Uses

Document staff hours of work, time off, leaves taken

Users

Department Leaders

Individuals in Bank

Employees (permanent and contract)

Retention and Disposal

Seven (7) years

Incident Reports

Critical Case Reviews

Purpose of the Record (Legal Authority)

Public Hospitals Act, Reg. 965

Description

Records relating to incident reviews conducted at Oak Valley Health

Location

Quality and Patient Safety

Record Format

Paper and Electronic

Type of Personal Information Maintained

Personal information and/or personal health information related to a patient’s care

Uses

Review of critical incidents to improve quality and patient safety

Users

Review team, care team, QCR Committee

Individuals in Bank

Patients

Retention and Disposal

10 years after discharge/death

10 years after patient’s 18th birthday 

Security Notebooks

Purpose of the Record (Legal Authority)

Criminal Code

Description

Note books of guards' incidents/ encounters or actions taken

Location

Security Office

Record Format

Paper

Type of Personal Information Maintained

Names, Medical Record Numbers (if applicable), description of incident or what the guard witnessed

Uses

Court testimonies (where applicable)

Users

Guards, Security Office

Individuals in Bank

Anyone involved in incident (employees, patients, visitors, etc.)

Retention and Disposal

Seven (7) years for any criminal investigation

Maintenance

Staff Files/Schedules

Purpose of the Record (Legal Authority)

Hospital Record Retention Policy

Description

Various types of records related to staff members, including hours of work and assignment areas

Location

Facilities and Corporate Services Office

Record Format

Paper and Electronic

Type of Personal Information Maintained

Training, payroll adjustments, disciplinary notes, performance review conversations

Uses

Variety depending on information

Users

Coordinators, Supervisors and Management

Individuals in Bank

Employees

Retention and Disposal

Seven (7) years

Occupational Health and Safety

Occupational Health Employee Records

Purpose of the Record (Legal Authority)

Occupational Health and Safety Act

Description

Records relating to the medical status, conditions, and recovery of individual Hospital employees. This includes matters where there are physical injuries and development of medical conditions causing disability or impairment, both work and non-work related. Documents may include doctors' notes and referrals, copies of resumes and training certificates, medical progress notes, and all supporting correspondence.

Location

Occupational Health and Safety

Record Format

Paper and Electronic

Type of Personal Information Maintained

Information relating to clarification of medical conditions, determination of whether and/or when an employee should return to work, confirmation of job duties the employee is and is not capable of performing, doctors' notes and referrals, medical progress notes, resumes and training certificates, all supporting correspondence

Uses

Assist with employee medical issues as they relate to employment

Users

Occupational Health and Safety

Individuals in Bank

All employees

Retention and Disposal

Permanent (for all staff and volunteers)

Occupational Reports and Records

Purpose of the Record (Legal Authority)

Occupational Health and Safety Act & Workplace Safety and Insurance Act

Description

Records relating to the hospital’s Occupational Health & Safety program to support and maintain safe and healthy workplace through working with the Joint Health & Safety Committee, and assessment of occupational hygiene, ergonomics and safety issues. 

Location

Occupational Health and Safety

Record Format

Paper and Electronic

Type of Personal Information Maintained

Employee/volunteer/persons with practicing privileges names, employee numbers, social insurance number, date of birth, contact information, test results and needs assessments, medical documentation related to absence and/or accommodation needs, employee incident and first aid reports, results of inspections and investigations, training conducted, plans to respond to accommodation needs and return to work issues, concerns related to workplace exposure to chemical, physical (noise, temperature, radiation) and/or biological agents, personnel concerns related to workstation and furniture design and configuration

Uses

Manage and respond to health and safety concerns and issues

Users

Occupational Health & Safety, information other than personal health information is used by employee leader as appropriate

Individuals in Bank

Employees/staff/volunteers/affiliates, those involved in an incident, and names of witnesses with respect to workplace incidents.

Retention and Disposal

40 years 

Workplace Safety and Insurance Board 

Purpose of the Record (Legal Authority)

Workplace Safety and Insurance Board (WSIB)

Description

Records relating to monitoring claims for compensation as a result of personal injuries, illness, or other medical conditions preventing employees from fulfilling regular job duties. 

Location

Occupational Health and Safety

Record Format

Electronic

Type of Personal Information Maintained

Employee name, injury report forms, workers' compensation and long term disability claim forms, Workplace Safety and Insurance Board (WSIB) forms, disability recurrence reports and supporting correspondence

Uses

Fulfill hospital's obligations to injured or ill employees including planning for workplace accommodation and safe return to work; to comply with legislation

Users

Occupational Health and Safety, Department Leaders (where appropriate) 

Individuals in Bank

All staff

Retention and Disposal

Permanent (NEER and monthly accident cost statements)

Patient Complaints Records

Patient Complaints and Feedback *FMPro

Purpose of the Record (Legal Authority)

Public Hospitals Act, Reg. 965

Description

When patients and families have feedback based on experiences within the hospital, they can seek out our Patient Relations process to confidentially file compliments, complaints, service alerts, and suggestions. This service is mandated under the Ontario Excellent Care for All Act (ECFAA).

Location

Patient Relations

Record Format

Electronic

Type of Personal Information Maintained

Patient information from medical record, complainant information including names and contact information, feedback provided, staff interviews and recollection of events

Uses

High level data and trends are shared hospital wide and with all programs through quarterly PREMs reporting.

Users

Director of Quality, Safety, Patient Experience and Relations & IPAC; Patient Relations Specialist; Quality and Safety Specialist

Individuals in Bank

Patients, family members, loved ones of patients

Retention and Disposal

Permanent

Pharmacy

Pharmacy Dispensing Records

Purpose of the Record (Legal Authority)

Drugs & Pharmacies Regulations Act, R.S.O.

Description

Records pertaining to patient prescriptions and dispensing of medication, including narcotics and controlled substances, and chemotherapy

Location

Pharmacy

Record Format

Paper and Electronic

Type of Personal Information Maintained

Patient name, medication prescribed, date of prescription, name of prescriber

Uses

Dispensing of prescribed drugs to patients

Users

Pharmacy staff, Care providers

Individuals in Bank

Patients who have been prescribed medication

Retention and Disposal

10 years + current year, destruction after 10 years

Schedules, Pharmacy Staff

Purpose of the Record (Legal Authority)

Employment Standards Act s. 15(5)

Description

Records pertaining to attendance and scheduling

Location

Pharmacy

Record Format

Paper and Electronic

Type of Personal Information Maintained

Leaves of absence, hours of work, overtime, statutory holidays, and sick time taken, vacation days, attendance, shift schedules

Uses

Document attendance, record and manage sick time

Users

Pharmacy staff  

Individuals in Bank

Pharmacy staff  

Retention and Disposal

Seven (7) years + current year, destruction after seven (7) years

Antibiotic Stewardship Program – Patient Review Forms

Purpose of the Record (Legal Authority)

Oak Valley Health Policy

Description

Documents related to providing activities under the ASP 

Location

Pharmacy shared drive

Record Format

Electronic

Type of Personal Information Maintained

Patient identifiers, medication history, treatment course in hospital

Uses

Medication history, treatment course in hospital

Users

ASP Pharmacists

Individuals in Bank

Patients with confirmed infection

Retention and Disposal

10 years

Privacy

FOI Request

Purpose of the Record (Legal Authority)

Freedom of Information and Protection of Privacy Act (FIPPA)

Description

Request forms for access to personal information or other records in the Hospital's custody and control

Location

Office of Access and Privacy

Record Format

Electronic

Type of Personal Information Maintained

Name and contact information of requestor, details of request, photo ID (where applicable) 

Uses

To process request

Users

Privacy Office

Individuals in Bank

Anyone who has submitted a request under FIPPA

Retention and Disposal

Three (3) years

Breaches

Purpose of the Record (Legal Authority)

Freedom of Information and Protection of Privacy Act (FIPPA)/Personal Health Information Protection Act (PHIPA)

Description

Privacy incidents reported either through iReport or by a patient, staff or whistleblower

Location

Office of Access and Privacy

Record Format

Electronic

Type of Personal Information Maintained

Details of incident, name of patient (where applicable), names and/or roles of staff involved in breach

Uses

To respond to privacy breaches; ensure all elements of privacy breach management protcol have been followed

Users

Multiple stakeholders depending on incident (department, individual(s) involved)

Individuals in Bank

Anyone who has reported or has been involved in a privacy breach incident (patients and/or staff)

Retention and Disposal

Three (3) years

PHIPA Request

Purpose of the Record (Legal Authority)

Personal Health Information Protection Act (PHIPA)

Description

Consent forms for access to personal health information

Location

Health Information Management 

Record Format

Paper and Electronic 

Type of Personal Information Maintained

Patient name, date of birth, other personal identifiers, description of treatment/personal health information requested

Uses

To process request

Users

To process release of information requests

Individuals in Bank

Patients/SDMs that have submitted a request under PHIPA

Retention and Disposal

Paper copy: 90 days                                      

Once request scanned into Meditech: 10 years after discharge/death, 10 years after patients 18th birthday

Consent Forms - Videotape/Audiotape/Photograph/Media Use

Purpose of the Record (Legal Authority)

Oak Valley Health Policy

Description

Consent form all patients must fill out if their photo and/or video is taken

Location

Public Relations

Record Format

Electronic 

Type of Personal Information Maintained

Name, phone number, address, email 

Uses

Promotional materials on website, social, brochures, etc.

Users

Communications

Individuals in Bank

Patients, employees, visitors

Retention and Disposal

Permanent

Risk Management

Risk Management File

Purpose of the Record (Legal Authority)

Public Hospitals Act, Reg. 965

Description

Documents maintained for legal claim purposes

Location

Risk Management

Record Format

Paper and Electronic 

Type of Personal Information Maintained

Statement of claim, health records, diagnostic imaging records, case review files, claims summary, third party reports, security reports/orders, maintenance reports, fetal heart monitor, other patient demographic information, employee and professional staff name/affiliation with Oak Valley Health/occupation

Uses

Defence of legal action

Users

Risk Management

Individuals in Bank

Patients, Employees

Retention and Disposal

Maintained for the duration of the legal claim; disposal at the direction of hospital legal representation

IReports/Incident Reports Occurrence Reports (Electronic)

Purpose of the Record (Legal Authority)

Public Hospitals Act, Reg. 965

Description

Incidents that are reported by staff for follow-up and investigation by necessary stakeholders

Location

Risk Management

Record Format

Electronic 

Type of Personal Information Maintained

Patient demographic information; employee and professional staff names, information about incident as reported by file author, follow-up notes by necessary stakeholders

Uses

Quality and patient safety analysis and improvement, legal claims

Users

Managers, Directors, Senior Leadership Team (SLT), Chief Executive Officer (CEO), Quality and Patient Safety, Integrated Risk Management

Individuals in Bank

Patients, Employees

Retention and Disposal

Maintained for the duration of the legal claim; disposal at the direction of hospital legal representation

Emergency Codes

Purpose of the Record (Legal Authority)

Public Hospitals Act, Reg. 965

Description

Notification/documentation of emergency code events 

Location

Risk Management

Record Format

Electronic 

Type of Personal Information Maintained

Employee/professional staff name,  patient demographic

Uses

Quality and patient safety analysis and improvement, legal claims

Users

Managers, Directors, SLT, CEO, Integrated Risk Management; Quality and Patient Safety

Individuals in Bank

Patients, Employees

Retention and Disposal

Maintained for the duration of the legal claim; disposal at the direction of hospital legal representation

SARS Records

Screening Tools

Purpose of the Record (Legal Authority)

Ministry of Health

Description

Screening questions 

Location

Infection Prevention and Control (IPAC) Office

Record Format

Paper

Type of Personal Information Maintained

Patient name, medical record number, symptoms experienced

Uses

Surveillance 

Users

IPAC and PH 

Individuals in Bank

Patients

Retention and Disposal

10 years or length of current action

Visitor Sign-in Sheets/Books

Purpose of the Record (Legal Authority)

Ministry of Health

Description

Sign-in sheets for visitors entering patient rooms 

Location

IPAC Office

Record Format

Paper

Type of Personal Information Maintained

Names

Uses

Surveillance 

Users

IPAC and PH 

Individuals in Bank

Visitors

Retention and Disposal

10 years or length of current action

Oak Valley Health Isolation Documentation

Purpose of the Record (Legal Authority)

Ministry of Health

Description

Patient isolation information 

Location

IPAC Office

Record Format

Paper

Type of Personal Information Maintained

Patient name, medical record number, symptoms experienced

Uses

Surveillance 

Users

IPAC and PH 

Individuals in Bank

Patients

Retention and Disposal

10 years or length of current action

Spiritual and Religious Care

Spiritual & Religious Care Applications

Purpose of the Record (Legal Authority)

Oak Valley Health Policy

Description

Volunteer or Clergy Privileges applications 

Location

Spiritual & Religious Care office

Record Format

Microfiche, Paper and Electronic

Type of Personal Information Maintained

Name, address, phone number, results of police check

Uses

Hiring and volunteer management

Users

Coordinator, Pastoral Care

Individuals in Bank

Anyone who has submitted an application form

Retention and Disposal

Permanent