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 our 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 organization 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
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
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)
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)
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)
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)
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
Employment Management
Users
Staff, Managers
Individuals in Bank
Community and Volunteer Resources Employees
Retention and Disposal
Seven (7) years from termination
Permanent (print copy)
Corporate Administrative records
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
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
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
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 Mohawk Medbuy posting
Users
Accounting
Individuals in Bank
Employees
Retention and Disposal
Seven (7) years
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
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
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
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
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
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
Seven (7) years
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 and Remittances
Users
Payroll
Individuals in Bank
Employees
Retention and Disposal
Seven (7) years
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
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
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
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
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
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
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
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
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
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
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
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
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
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)
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
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
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)
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
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
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
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
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
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
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)
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
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
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
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
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)
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
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
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
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
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
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
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
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
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
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
Purpose of the Record (Legal Authority)
Public Hospitals Act, Reg. 965
Description
Documents maintained for legal claim purposes
Location
Risk Management
Record Format
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
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
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
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
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
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
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