Records Retention Policy

Abstract:
This policy establishes guidelines requiring all UAB operating units to institute and implement an appropriate records management program.

Review/Revised Date: 09/13/2013

Category: Financial Affairs

Policy Owner:

Policy Contact:

Definitions

The following defined terms are used for purposes of administering this policy but may be defined differently elsewhere in other UAB policies and materials:

Records – Any documentary material, regardless of physical form or characteristic, that is generated, received or maintained by UAB in connection with transacting its business, is related to the UAB’s legal obligations, and is retained for any period of time.

Non-Records – Non-records include duplicate copies of correspondence, magazines, publications from professional organizations, newspapers, and public telephone directories.  Instant messages are considered non-records.  E-mail communications shall be considered non-records; however, to the extent an e-mail message meets the criteria of a specific record type defined herein, the e-mail message should be preserved according to the retention schedule for the subject record type by saving it electronically separately from the e-mail system or printing a hard copy.  The retention schedules do not apply to non-records.  Non-records should be disposed of when the business use is completed.

Records Management – The planned and systematic control of business records from their creation through final disposition.  Records should only be destroyed when the specified retention period has expired.

Permanent Records – Records that are ineligible for destruction.

Vital Records – Official records that are considered essential to the continuity of UAB.  Without such records, business would be significantly impaired as they are necessary for the recreation of the business.  Such records are essential to the continuation of operations, are essential to UAB’s legal and financial status, denote ownership of assets which would otherwise be difficult or impossible to establish, and are necessary for fulfillment of obligations to employees, patients, and/or outside interests.

Litigation – Any reasonably anticipated litigation, audit, governmental investigation, or similar proceeding.

Litigation Hold – The identification and preservation of those records or non-records reasonably related to litigation.

Policy Statement

The management of records from creation to destruction should be accomplished in a uniform manner that promotes compliance with laws, regulations, and judicial proceedings, promotes appropriate business objectives, and allows for the management, maintenance, and replacement of associated information systems technology in an efficient and cost-effective manner.

Litigation

Office of Legal Counsel shall be responsible for interpreting any portions of this Policy statement as they may apply to specific situations. In the event of any actual or reasonably anticipated litigation, audit, governmental investigation, or similar proceeding (collectively, “litigation”), records and non-records potentially related to the litigation may not be destroyed and must be preserved until the litigation is closed and the retention period has otherwise expired. Accordingly, the destruction of all records and non-records under this policy potentially related to the litigation will be suspended upon commencement of the litigation, or when litigation is reasonably anticipated, so that appropriate steps can be taken to identify and preserve those records or non-records reasonably related to the litigation (a “litigation hold”).

After the litigation hold is implemented, the prior suspension of this policy as to any affected records or non-records determined not to be subject to the litigation hold will be lifted, and the retention periods specified herein will apply thereafter.  The suspension of destruction and preservation of records and non-records potentially related to litigation as described above shall apply to all records and non-records, regardless of the form in which they are maintained, including without limitation e-mail, documents or files stored on computers, databases, any other electronically stored information, as well as hard copy documents and files.  Records for which the legal, fiscal, administrative, and archival requirements have been satisfied may be destroyed in accordance with the recommended minimum record retention schedules. When in doubt, confer with legal counsel before disposing of any record.

Recycling

Recycling is the preferred method to destroy records.  The designated recycling/shredder company must guarantee that the records were destroyed and are no longer recognizable as records.  The recycling/shredder company shall maintain a log or certificate of destruction indicating the types and quantities of records destroyed, the method of destruction, the destruction date, and agreeing to maintain the confidentiality of the documents it destroys. The recycling/shredder company shall execute a Business Associate Agreement in conformance with the HIPAA privacy laws and regulations in a form satisfactory to UAB Health System and its Operating Entities.

Exceptions

Requests for exceptions from this Policy shall be submitted to the leadership designated within each responsible department listed in the UAB Records Retention Schedule.  In order to obtain an exception from this Policy, there shall be a process that will assure compliance with the basic objectives as stated herein.  Requests shall be made pursuant to the Request for Exception to Records Management Policy Record Retention Schedule.

Records Storage

Records shall be stored in safe/secure locations and protected from environmental and other potential harm, including:

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

Man-made hazards such as theft, accidental loss; and

Unauthorized use, disclosure, and destruction.

Authorized personnel shall label records storage containers in sufficient detail to facilitate prompt and accurate content identification.  Records shall be filed in records storage containers by year or other specified identification method to facilitate their reference, review and destruction.

Vital Records shall be duplicated and the duplicate records stored at off-site locations, separate from corporate records, for reconstructive use in the event of a disaster.

Electronic or Imaged Records

The procedures and records retention periods set forth in this Policy shall be applicable to electronically stored Records.  Records generated and maintained in information systems or equipment are to be periodically reviewed by applicable information owners and/or custodians to ensure that record retention requirements set forth in this Policy are being met for electronic information systems.

The use of disc (CD, DVD), or similar searchable and immediately readable electronic media for Records storage purposes is encouraged.  Tapes, CD, DVD, and other digital media must be appropriately labeled as to the sensitivity level of the information, date range of the material stored, and any special storage requirements.

User departments should make reasonable efforts to assure special packaging, handling and environmentally controlled facilities are in place.

Refer to the HIPAA core standard for Media Reallocation and destruction for appropriate methods of disposal.

E-Mail

E-mail systems facilitate both internal and external business communications on a day-to-day basis.   Messages contained on eail systems are kept for a limited period of time.  E-mail systems therefore should not be considered, or used as, an information archival or storage system.  As stated above, e-mail messages that meet the criteria of a Record defined herein should be preserved in hard copy or stored electronically separately from eail systems for record retention and archival purposes.

Magnetic Tapes

Magnetic tapes, usually referred to as “back-up tapes,” are not to be used for Records storage or information archival purposes.  Back-up tapes generally are not searchable, cannot be read without a costly and time-consuming restoration process, and typically cannot be read without special equipment and specially trained personnel.  Back-up tapes serve a disaster recovery function for specific information systems and not a Records retention or archival function.

Film

The storage procedures and records retention periods set forth in this Policy shall be applicable to information contained or stored on film media, including microfilm, microfiche, or similar media.  The use of film for record storage and retention purposes should be selective to ensure cost effectiveness.  Standard practices are to be developed and utilized when reducing information to film to ensure that authenticity is not impaired.

Minimum Recommended Record Retention Periods

All records shall be retained in accordance with Federal and state laws and regulations.  Records maintained by UAB must be maintained in accordance with the Public Universities of Alabama Functional Analysis and Records Disposition Authority.  Records maintained by UAB-owned Healthcare Authorities must be maintained in accordance with the Health Care Authorities Records Disposition Authority published by the Alabama Local Government Records Commission.  For policies related to records maintenance in operating entities of the UAB Health System, please contact Policies & Standards Resources.

The recommended retention period for each category of records is outlined in the Records Retention Schedule.  The Records Retention Schedule takes into account the minimum retention periods for records subject to the above sections relating to Public Universities and Health Care Authorities.

Purpose

Scope

Definitions

Policy Statement

Minimum Recommended Record Retention Periods

Disposal of University Records

Implementation