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SickKids

Records Inventory

SickKids is required by the Freedom of Information and Protection of Privacy Act (FIPPA) to produce a Records Inventory – a listing of the general classes of records (GCR) held by the hospital.

The Records Inventory includes the following:

  • The title and type of the class of records 
  • A description of the type of information that is maintained in this class of records 
  • The location of this class of records 
  • The retention and disposal (how long the information is kept) 

The Records Inventory and listing of Personal Information Banks can be helpful for formulating clear and defined requests. It is important to remember that while these tools can be useful in defining the types of records held by SickKids, 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 through an Freedom of Information (FOI) request.

Academic

Type 

GCR/PIB

Authority 

Freedom of Information and Protection of Privacy Act

Description

Records relating to staff learning opportunities including iLearn and external
education events.  

Location

Learning Institute and Clinical areas

Format 

Electronic and Paper

Information Maintained 

Name, learning items history and status, education history, funding amounts,
attendance.

Uses 

Track compliance, learning item, application, approval and reimbursement status

Users 

Staff, Managers, Educators, iLearn Administrators, Learning Institute SCPDF team

Individuals in Bank 

Staff, Physicians/Dentists, Residents, Fellows, Students and Volunteers

Retention and Disposal 

TBD

Type 

GCR

Description 

Resources created for families and staff related to patient safety.

Location 

Quality and Risk Management

Retention and Disposal 

TBD

Administration

Type

GCR

Description

Annual Reports of The Hospital for Sick Children.

Location

Executive Office

Retention and Disposal

Five years

Type

 GCR

Description

Records relating to the independent review of the Hospital

Location 

Quality and Risk Management

Retention and Disposal 

10 years for report; educational information until superseded

Type

PIB

Authority 

Freedom of Information and Protection of Privacy Act

Description 

Records related to the photography or videotaping of staff, patients, visitors or members of the public.

Location

Common

Information Maintained 

Name, contact information, medical history

Uses 

Creation of educational resources, media stories

Users 

Communications and Public Affairs, Learning Institute

Individuals in Bank 

Individuals who agree to take part in photography or video recordings by The Hospital for Sick Children

Retention and Disposal 

2 years past the date of creation

Type 

GCR

Description 

Agreements and contracts between the Hospital and third party organizations.

Location 

Common

Retention and Disposal

The greater of 7 years or the life of the agreement plus 2 years

Type 

GCR

Description 

Records relating to leases and deeds of The Hospital for Sick Children.

Location 

Legal Services

Retention and Disposal 

Life of the Agreement + 10 years

Type 

GCR

Description 

Records relating to the incorporation of The Hospital for Sick Children

Location 

Executive Office

Retention and Disposal 

Life of the Hospital + 5 years

Type

GCR-PIB

Authority 

Freedom of Information and Protection of Privacy Act

Description 

Records relating to administration of requests for access under the Freedom of Information and Protection of Privacy Act.

Location 

Freedom of Information Office 

Format 

Paper, Electronic

Information Maintained 

Name and contact information of requesters, third parties, complainants

Uses 

Respond to requests for access, correction, complaints

Users 

Freedom of Information  Office staff; Information & Privacy Commissioner

Individuals in Bank

Individuals who make access requests, requests for correction or complaints

Retention and Disposal 

TBD

Type 

GCR

Description 

Record of discussions and agreements related to the Local Health Integration Network (LHIN).

Location 

Executive Office

Retention and Disposal 

Life of the Hospital + 5 years

Type

GCR

Description

Records relating to Hospital Administrative Committees, excluding the Joint Health and Safety Committee and Patient Care Committees

Location

Committee Chair

Retention and Disposal

3 years

Type

GCR

Description

Records relating to Patient Care Committees including agendas and minutes

Location

Committee Chair

Retention and Disposal

15 years

Type

GCR

Description

Records related to the Joint Health and Safety Committee including minutes and agendas

Location

Occupational Health and Safety

Retention and Disposal

6 years

Type

GCR

Description

Records relating to meeting of Senior Management including agendas and minutes

Location

Executive Office

Retention and Disposal

3 years

Type

GCR

Description

Records relating to staff meetings including agendas and minutes

Location

Meeting Chair

Format

Paper, Electronic

Retention and Disposal

1 year

Type

GCR

Description

Records related to meetings of the Research Ethics Board

Location

Research Ethics Board

Retention and Disposal

25 years

Board and Governance

Type

GCR

Description

By-laws passed by The Hospital for Sick Children

Location

Executive Office

Retention and Disposal

Life of the Hospital + 5 years

Type

GCR

Description

Listing of current and former members of the Board of Directors of The Hospital for Sick Children

Location

Executive Office

Format

Paper, Electronic

Retention and Disposal

Life of the Hospital + 5 years

Type

GCR

Description

Records relating to meetings of the Board of Trustees and Standing Committees of the Board

Location

Executive Office

Retention and Disposal

Minutes of the Board of Trustees: Life of Hospital + 5 years; Minutes of the Standing Committees of the Board: 15 years

Clinical/Health Records

Type

GCB/PIB

Authority

Public Hospitals Act R.S.0 1990, c. P.40; Health Protection & Promotion Act; O. Reg. 49/07

Description

Records related to Infection Prevention and Control at The Hospital for Sick Children

Location

Infection Prevention and Control

Format

Paper, Electronic

Information Maintained

Patient name, MRN number, other patient demographic information as required based on outbreak type

Uses

To report and track outbreaks as required by Toronto Public Health

Users

Infection Prevention and Control; Toronto Public Health

Individuals in Bank

Patients diagnosed with a  reportable disease in an outbreak 

Retention and Disposal 

TBD

Type

GCR

Description 

Records related to the ratio of actual (observed) deaths to expected deaths 

Location

Common

Retention and Disposal

TBD

 

Type

PIB

Authority

Public Hospitals Act R.S.0 1990, c. P.40

Description

Register of all patients receiving care at the Hospital 

Location

Common - Clinical areas

Format

Paper, Electronic

Information Maintained

Patient name, demographic and contact information, medical record number and OHIP number, date of visit and reason for visit, primary care and attending physician, emergency contact information, length of stay

Uses

Used to accurately identify patients and to link patient care information to the correct patient; maintain a complete record of all patient visits

Users

Registration staff, care providers, patient accounts

Individuals in Bank

Patients

Retention and Disposal

50 years

Type

PIB

Authority

Public Hospitals Act R.S.0 1990, c. P.40

Description

Record of the care and treatment provided to patients

Location

Health Records

Format

Paper, Electronic

Information Maintained

Please see Patient Register; medical condition and diagnostic information, test results, medications, records relating to any surgery or medical procedures 

Uses

In the provision of care; to document the history of patient care; in the evaluation of quality of care and service provision; for research approved by Research Ethics Board

Users

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

Individuals in Bank

Patients

Retention and Disposal

33 years from the date of last entry or death 

Type

PIB

Authority

Public Hospitals Act R.S.0 1990, c. P.40

Description

Record of the care and treatment provided to patients

Location

Health Records

Format

Paper, Electronic

Information Maintained

Please see Patient Register; medical condition and diagnostic information, test results, medications, records relating to any surgery or medical procedures 

Uses

In the provision of care; to document the history of patient care; in the evaluation of quality of care and service provision; for research approved by Research Ethics Board

Users

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

Individuals in Bank

Patients

 

33 years from the date of last entry or death 

Type

PIB

Authority

Public Hospitals Act RS.0 1990, c. P.40

Description

Medical images of patients

Format

Electronic

Information Maintained

Please see Patient Register; diagnostic images

Uses

Diagnosis and care and treatment of patient

Users

Care providers

Individuals in Bank

Patients

Retention and Disposal

Adult: at least 5 years after the day on which the image is created. Children under 18 years: at least 5 years after the patient's 18th birthday

Type

PIB

Authority

Public Hospitals Act R.S.0 1990, c.P.40

Description

Records relating to registration and admitting of patients

Location

Health Records

Format

Paper, Electronic

Information Maintained

Patient name, demographic and contact information, medical record number and OHIP number, date of visit and reason for visit, name of primary care and attending physician, emergency contact information, length of stay

Uses

Maintained a record of Patient visits to Hospital

Users

Registration staff, care providers

Individuals in Bank

Patients

Retention and Disposal

33 years from date of last entry or death

Type

PIB

Authority

Drugs & Pharmacies Regulations Act, R.So. 1990 c. H. 4

Description

Records of inpatient and outpatient drug prescriptions 

Location

Pharmacy

Format

Paper

Information Maintained

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

Uses

Dispensing of prescribed drugs to patient

Users 

Pharmacy staff

Individuals in Bank

Patients who have been prescribed medication

Retention and Disposal

TBD

Type 

PIB

Authority

Personal Health Information Protection Act, 2004, S.O. 2004, c. 3, Sched. A. 

Description

Record of all corrections to patient personal health information

Location

Health Records

Format

Paper

Information Maintained

Patient Name/MRN, date requested correction, original document, corrected document, date of response with letter if applicable

Uses

List and requests of all corrections made by parent/patient 

Users

Health Records

Individuals in Bank

Patients who have requested a correction to their personal health information

Retention and Disposal

33 years from the date of death or last entry

Type

GCR

Description

Record of Destruction of the Patient Chart

Location

Health Records

Retention and Disposal

Permanent

Communications and Public Relations

Type

GCR

Description

Records relating to the communication programs at The Hospital for Sick Children

Location

Communications and Public Affairs

Retention and Disposal

TBD

Equipment and Supplies

Type

GCR

Description

Records relating to the servicing of elevators at The Hospital for Sick Children

Location

Plant and Facilities

Retention and Disposal

5 years from the date of last entry

Type

GCR

Description

Records related to the cleaning and reprocessing of medical equipment

Location

Central Services

Retention and Disposal

2 years

Type

GCR

Description

Records relating to the management and tracking of medical equipment used in the Hospital

Location

Medical Engineering

Retention and Disposal

Life of the instrument plus 2 years

Type

GCR

Description

Records relating to the installation, maintenance, operation, and use of telecommunications equipment and systems

Location

Information Services

Retention and Disposal

TBD

Type

GCR

Description

Records relating to the management and tracking of operational equipment and furnishing used in the Hospital

Location

Plant Operations

Retention and Disposal 

TBD

Facilities Management

Type

GCR/PIB

Authority

Freedom of Information and Protection of Privacy Act

Description

Records related to the management of property owned or leased by The Hospital for Sick Children

Location

Business Development Services

Information Maintained

Staff name, vehicle identification information, reference information, personal address

Uses 

Tracking and Quality Assurance

Users

Business Development Services and Property Management staff

Individuals in Bank 

Patients/Staff

Retention and Disposal

2 years

Type

GCR

Description

Records relating to the maintenance of the electrical, mechanical and ventilation infrastructure at The Hospital for Sick Children and affiliated buildings

Location

Facilities Planning and Development

Retention and Disposal

10 years from the date of the document  

Type

GCR

Description

Records relating to planning, preparation and implementation of fire safety

Location

Drawings: Facilities Planning and Development; Tests and Inspections: Protection Services

Retention and Disposal

Drawings: 15 years after lift of subject matter; Tests and Inspections: 2 years after inspection or test date

Type

GCR

Description

Records relating to the development of Hospital sites

Location

Facilities Planning and Development

Retention and Disposal

Permanent

Type

GCR

Description

Records relating to workplace and space requirements, planning and implementation 

Location

Facilities Planning and Development

Retention and Disposal

10 years from date of document

Type

GCR

Description

Drawings and blueprints of The Hospital for Sick Children

Location

Facilities Planning and Development

Retention and Disposal

15 years after the life of the subject matter

Finance

Type

GCR

Description

Records relating to management of financial responsibilities 

Location

Finance

Retention and Disposal

TBD

Type

GCR

Description

Records relating to procurement processes

Location

Procurement 

Retention and Disposal

7 years

Type

GCR

Description

Records relating to management and administration capital and operating budgets

Location

Common

Retention and Disposal

TBD

Type

GCR/PIB

Authority

Public Hospitals Act R.S.0 1990, c. P.40

Description

Billing and remittance documentation including patient, institutional and other governmental agencies, and the Ministry of Health and Long Term Care (MOHLTC)

Location

Finance

Format

Paper, Electronic

Information Maintained

Name, address or telephone number, age, sex, marital status or family status, MRN no., educational/financial/criminal/employment status or history, Credit Card No. Health Card No., Individuals substitute decision maker, eligibility or payment for health care donation or transplant of body parts or testing or examination of parts of substances, identification or person providing care. 

Uses

To support hospital revenue transactions and issue billings

Users 

Finance/Patients/MOHLTC/External Institutions/government

Individuals in Bank

Patients & Parents

Retention and Disposal 

7 years

Type

GCR/PIB

Authority

Health Insurance Act R.R.O. 1990, Regulation 552

Description

Records relating to claims submitted to the Ministry of Health & Long Term Care in respect of treatment and services provided to patients under the Ontario Health Insurance Plan

Location

Finance

Format

Electronic

Information Maintained

Name of patient, OHIP number, whether an ambulance service was used, date of admission and discharge, treatment and services provided including reasons

Uses

Receive payment for insurable treatment and services provided to patients

Users

Care providers, Finance

Individuals in Bank

Patients

Retention and Disposal

11 years

Type

GCR

Description

Records integral to the creation of financial statements

Location

Finance

Retention and Disposal

10 years

Type 

GCR/PIB

Authority

Public Hospitals Act R.S.0 1990, c. P.40

Description 

Records relating to processing payments mad the the Hospital

Location

Finance

Format

Electronic, Paper

Information Maintained

Supplied name, address, receipts, invoices, expense claim statements, payments certificates, financial transactions, staff ID number, SIN number, name and address

Uses

To support hospital expense transactions

Users

Finance staff

Individuals in Bank

Employees, individuals providing goods and services to the Hospital

Retention and Disposal

10 years

Type

GCR

Description

Records related to External Funding

Location

Finance

Retention and Disposal

7 years

Type

GCR

Description

Records relating to payments for services made to the Hospital

Location

Finance

Retention and Disposal

10 years

Type

GCR

Description

Records related to inventory reporting

Location

Finance

Retention and Disposal 

7 years

Type

GCR

Description

Records relating to baking

Location

Finance

Retention and Disposal

10 years

Type

GCR

Description

Records related to tax remittance

Location

Finance

Retention and Disposal

10 years

Type

GCR

Description

Records relating to financial analysis and reporting at The Hospital for Sick Children

Location

Finance

Retention and Disposal

TBD

Human Resources

Type

PIB

Authority

Employment Standards Act s. 15(5)

Description

Records relating to the attendance and scheduling

Location

Common

Format

Electronic, Paper

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

Human Resources, Managers

Individuals in Bank

Employees, contract and permanent

Retention and Disposal

3 years

Type

GCR/PIB

Authority

Public Hospitals Act R.S.0 1990, c. P.40

Description

Records relating to benefit plans offered to eligible staff and retirees that provide full or partial financial coverage to eligible Hospital employees, retirees and/or their families

Location

Human Resources

Format

Paper, Electronic

Information Maintained

Employee ID, name, DOB, sex, marital status, telephone number, beneficiary information

Uses

Enrolment and administration of benefit plans

Users

Human Resources staff

Individuals in Bank

Employees

Retention and Disposal

TBD

Type

PIB

Authority

Public Hospitals Act R.S.0 1990, c. P.40

Description

Records relating to the recruitment of staff for permanent, part-time, and contract job postings

Location

Human Resources

Format

Electronic, Paper

Information Maintained

Submitted resumes and/or job applications, containing information on employment history, education, and contact information

Uses

Document competition and hiring processes

Users

Human Resources - Talent Management

Individuals in Bank

Hospital employees and members of the public applying for positions at The Hospital for Sick Children

Retention and Disposal

TBD

Type 

PIB

Authority

Employment Standards Act, S.O. 2000, c. 41, s. 15

Description

Records relating to the employment of SickKids staff

Location

Human Resources

Format

Electronic, Paper

Information Maintained

Employee number and name, application form, benefits options, education, work history, attendance and leave records, performance evaluations, disciplinary actions, WSIB records

Uses

To document work history

Users

Human Resources, other Managers as appropriate

Individuals in Bank

Staff

Retention and Disposal

3 years after the date to which the record relates

Type

PIB

Authority

Employment Standards Act, S.O. 2000, c. 41, s. 15

Location

Human Resources

Format

Paper, Electronic

Information Maintained

Staff name, start date, address, date of birth

Uses

Document work history

Users 

Human Resources staff

Individuals in Bank

Staff

Retention and Disposal

3 years after departure if the staff member to whom it relates

Type 

GCR/PIB

Authority

Employment Standards Act, 2000, c.41, s.11; Insurance Act, R.S.O. 1990, c.1.8, s.300; Canada Pension Plan, R.S. 1985, C. C-8

Description

Records relating to individual employees' pay history profiles

Location

Human Resources

Format

Electronic, Paper

Information Maintained

Employee number, name, address, sex, social insurance number, date of birth, marital status, telephone number, tax exemptions, employee benefit information, bank account number, name of group life and pension beneficiary

Uses

Calculate and administer payroll; administer employee benefits and pensions

Users

Finance and Human Resources staff

Individuals in Bank

Staff

Retention and Disposal

6 years from the end of the fiscal year to which they relate

Type

GCR/PIB

Authority

Pension Benefit Act, R.S.O. 1990, c. P.10

Description

Records relating to SickKids pension plans and individual deductions

Location

Human Resources

Format

Electronic, Paper

Information Maintained

Pension contribution deduction amount

Uses

Document staff pension deductions

Users 

Finance

Individuals in Bank

Staff

Retention and Disposal

TBD

Type 

PIB

Authority

Public Hospitals Act R.S.O 1990 c. P. 40

Description

Records relating to the appointment of Physicians and Dentists practicing at The Hospital for Sick Children

Location

Medical Affairs

Format

Paper, Electronic

Information Maintained

Name, address, date of birth, photo, academic information, visa information, emergency contact, email address

Uses

Credential physicians and dentists and appoint them to the Medical/Dental staff

Users

Medical Affairs, Quality Risk, Clinical Departments

Individuals in Bank

Staff physician and Dentists: contract and cross appointed

Retention and Disposal

End of the last appointment year plus 15 years

Type

PIB

Authority

Public Hospitals Act R.S.O 1990 c. P. 40

Description

Records related to fellowships, observerships and residencies at The Hospital for Sick Children

Location

Medical Affairs

Format

Electronic, Paper

Information Maintained

Name, contact information, evaluations, program information

Uses

Program planning and information related to patient care

Users

Affiliated educational institution, program committees, departments

Individuals in Bank

Fellows, Residents, Observers

Retention and Disposal 

Fellows and Residents: 15 years; Observers: 6 months past the time they leave

Type

GCR

Description

Records relating to the Hospital's relationship with its workforce

Location

Human Resources

Retention and Disposal

TBD

Type

PIB

Legal Authority

Public Hospitals Act, R.S.O 1990 c. P.40

Description

Records relating to volunteers at The Hospital for Sick Children

Location

Human Resources

Format

Electronic, Paper

Information Maintained

Name and contact information of volunteers, length of service

Uses

To contact and/or schedule volunteers

Users

Volunteer Services

Individuals in Bank

Volunteers at The Hospital for Sick Children

Retention and Disposal

TBD

Information Systems

Type

GCR

Description

Records relating to installation and maintenance of computer hardware

Location

Information Services

Retention and Disposal

TBD

Type

GCR

Description

Records relating to computer software which are programs that are used with various computer and operating systems 

Location

Information Services

Retention and Disposal

TBD

Type

GCR

Description

Records relating to the development, implementation, and support of computer system applications used by the Hospital

Location

Information Services

Retention and Disposal

TBD

Type

GCR

Description

Records relating to the development, implementation and support of Hospital computer system applications

Location

Information Services

Retention and Disposal

TBD

Type

GCR

Description

A record relating to the Hospital's interconnected computing systems and components

Location

Information Services

Retention and Disposal

TBD

Type

GCR

Description

Records relating to the security and confidentiality of the Hospital's electronic information resources

Location

Information Services

Retention and Disposal

TBD

Legal

Type

GCR

Description

Records relating to the administration of, and consultation in respect of legal matters and litigation affecting or initiated by the Hospital

Location

Common

Retention and Disposal

Until in the opinion of Quality and Risk Management and Legal Counsel, the matter has been finally resolved by way of settlement of judgement and all applicable appeal periods are exhausted

Type

GCR

Description

Records related to the provision of legal advice by internal or external Counsel

Location

Common

Retention and Disposal

TBD

Occupational Health and Safety

Type

PIB

Authority

Occupational Health and Safety Act, R.S.O. 1990, c. O.1, s.26

Description

Records relating to the medical status, condition, and recovery of individual Hospital employees

Location

Occupational Health and Safety

Format

Electronic, Paper

Information Maintained

Information about staff member's medical conditions and whether he/she can return to regular work duties

Uses

Assist with employee medical issues as they relate to employment

Users

Occupational Health and Safety staff

Individuals in Bank 

Staff

Retention and Disposal

TBD

Type

GCR/PIB

Authority

Occupational Health and Safety Act, R.S.O. 1990, c. O.1, s9. Occupational Health and Safety Act, R.S.O. 1990, c.O.1, s26. Workplace Safety- Insurance Act, 1997

Description

Records relating to staff immunization

Location

Occupational Health and Safety

Format

Paper, Electronic

Information Maintained

Name, badge number, immunization status

Uses

Track immunization data for staff safety during outbreaks

Users

Occupational Health and Safety staff

Individuals in Bank

Staff, volunteers

Retention and Disposal

TBD

Type 

GCR/PIB

Authority

Occupational Health and Safety Act, R.S.O. 1990, c. O.1, s9. Occupational Health and Safety Act, R.S.O. 1990, c.O.1, s26. Workplace Safety and - Insurance Act, 1997

Description

Records relating to the storage, use, and disposal of biological agents and records relating to worker exposure to chemical or biological agents

Location

Occupational Health and Safety

Format

Electronic, Paper

Information Maintained 

Employee names, test results, concerns about health, safety, accommodation needs

Uses

To respond to health and safety concerns and issues

Users

Occupational Health and Safety staff

Individuals in Bank

Staff who have been involved in an incident 

Retention and Disposal

40 years

Type

GCR/PIB

Authority

Occupational Health and Safety Act, R.S.O. 1990, c. O.1, s9. Occupational Health and Safety Act, R.S.O. 1990, c.O.1, s26. Workplace Safety and Insurance Act, 1997

Description

Notice of accidents and records relating workplace incidents/accidents

Location

Occupational Health and Safety

Format

Paper, Electronic

Information Maintained

Names, details related to incidents, medical information

Uses

Respond to health and safety concerns and issues

Users

Occupational Health and Safety staff and Joint Health & Safety Committee, Human Resources 

Individuals in Bank

Staff who have been involved in an incident or accident

Retention and Disposal 

40 years

Type 

GCR/PIB

Authority

Occupational Health and Safety Act, R.S.O. 1990, c. O.1, s9

Description

Records relating to radiation exposure and Radionuclides 

Location

Research Institute, Diagnostic Imaging

Format

Paper, Electronic

Information Maintained

Name, information related to exposures, work history

Uses

Record radiation exposure and Radionuclides in staff

Users

Research Institute, Diagnostic Imaging

Individuals in Bank

Staff/Researchers exposed to radiation and/or radionuclides

Retention and Disposal

Permanent

Patient and Family Relations

Type

PIB

Authority

Public Hospitals Act. R.S.0 1990, c. P.40

Description

Records relating to patient complaints and patient feedback

Location

Patient and Family Relations

Format

Paper, Electronic

Information Maintained

Name and contact information of individual complimenting or complaining about some aspect of their Hospital experience; information relating to the nature of the complaint or compliment 

Uses

Respond to concern or complaint; evaluate and improve program and service delivery

Users

Patient and Family Relations

Individual in Bank

Individuals making a complaint/concern or providing feedback related to care at SickKids

Retention and Disposal

2 years from the date of file closure

Type

GCR

Description

Insurance policies held by the Hospital

Location

Quality and Risk Management

Retention and Disposal

Claims-made policies: until the expiration of the policy; Claim-incurred policies: life of the Hospital or a minimum of 15 years from the end of the policy; Fire insurance: 1 year after termination of the policy

Type

GCR

Description

Current and archived clinical and administrative policies

Location

Quality and Risk Management

Retention and Disposal

Corporate policies: 15 years after archiving, Patient Care related policies: 33 years

Publications and Conferences

Type

GCR

Description

Records relating to publications by The Hospital for Sick Children, its staff or individuals associate with the Hospital

Location

Common; Research Publication: Principal Investigator 

Formation

Paper, Electronic

Retention and Disposal

3 years; Research Publications: 5 years after the end of the study

Quality and Risk Management

Type

GCR

Description

Report of patient satisfaction

Location

Quality and Risk Management

Retention and Disposal

10 years

Type

GCR/PIB

Authority

Quality of Care Information Protection Act, 2004, S.O. 2004, c. 3, Sched. B; Public Hospitals Act R.S.0 1990, c. P.40

Description

Records relating to the assessment and evaluation of the quality of health care provided and related to programs and services

Location

Quality and Risk Management, Clinical areas

Format

Electronic

Information Maintained

Patient name and contact information, patient health information, care and treatment provided and adverse events

Uses

To evaluate care and service delivery and care and improve the quality of care and services provided to patients

Users

Quality and Risk Management staff, Clinical areas

Individuals in Bank

Patients

Retention and Disposal

Until opportunity for appeal or legal action has passed

Type

GCR/PIB

Authority

Public Hospitals Act R.S.0 1990, c. P.40

Description

Reports relating to incidents occurring in the Hospital or on Hospital property where an individual has been or may have been injured

Location

Quality and Risk Management

Format

Paper, Electronic

Information Maintained

Name and contact information of involved individuals, detail of injury or possible injury including related circumstances

Uses

To improve safety, to inform affected parties and to respond to any issues related to the matter

Users

Quality and Risk Management

Individuals in Bank

Patients or visitors who have or may have been injured

Retention and Disposal

Until opportunity for appeal or legal action has passed

Authority

ICH Good Clinical Practice Guidelines; Personal Health Information

Type

GCR/PIB

Authority

Personal Health Information Protection Act, 2004, S.O. 2004, c. 3, Sched. A. 

Description

Reports related to quality and risk audits

Location

Quality and Risk Management

Format

Paper, Electronic

Information Maintained

Patient names, MRN, unit, responsible physician

Uses

Indicator reports for scorecard, accreditation indicator

Users

The Hospital for Sick Children staff

Individuals in Bank

Patients

Retention and Disposal

Medication Reconciliation Audit: 1-2 months; All others: TBD

Type

PIB

Authority

Personal Health Information Protection Act, 2004, S.O. 2004, c. 3 Sched. A; Quality of Care Information Protection Act, 2004, S.O. 2004, c. 3, Sched B

Description

Records relating to critical incident reviews conducted at The Hospital for Sick Children

Location

Quality and Risk Management

Format

Paper, Electronic

Information Maintained

Clinical information related to care

Uses

Review of critical incidents

Users

Review Team, Executive Sponsors, Risk and Associate Risk Manager

Individuals in Bank

Patients

Retention and Disposal

10 years after final disposition of complaint

Research

Type

GCR/PIB

Description

Records related to research

Location

Principal Investigator

Formation

Paper, Electronic

Information Maintained

Curriculum vitaes of REB Members, REB Training Records, Personal Health Information of Research Subjects

Uses

Clinical Research

Users

Principal Investigator, REB

Individuals in Bank

REB members, Research participants

Retention and Disposal

Clinical regulated trials (i.e. registered with Health Canada): 25 years from creation of document; Non-clinical trials and Animal use protocols: 7 years

Type

GCR

Description

Records relating to audits by Health Canada

Location

Clinical Research Office

Retention and Disposal 

TBD

Type

GCR

Description

Records related to regulatory compliance in research

Location

Common

Format

Electronic, Paper

Retention and Disposal

Various

Type

GCR

Description

Records relating to conflict of interest disclosure associate with research

Location

Research Faculty Office

Retention and Disposal

7 years after the end of the study

Type

GCR

Description

Records relating to alleged research misconduct

Location

Office of the Chief of Research

Retention and Disposal

7 years after the end of the study

Security

Type

GCR/PIB

Authority

Public Hospitals Act R.S.0 1990, c. P.40

Description

Records relating to providing security for patients, visitors, staff, physicians and volunteers at The Hospital for Sick Children

Location

Protection Services

Format

Paper, Electronic

Information Maintained

Names of staff, physicians and volunteers, identification number and photograph; images of persons at Hospital entrances and main hallways captured by video surveillance

Users

To identify staff, physicians and volunteers and document access; videotaping and monitoring is used to identify and respond to potential security risks

Users

Protection Services

Individuals in Bank

Hospital staff, patients, visitors, families, volunteers, members of the public

Retention and Disposal

Video Surveillance: 30 days; Security Reports: 2 years

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