HOSPITAL SERVICES SECTION 3
2014-HEALTHPEI-01
SECTION 1) HEALTH PEI - GENERAL SECTION 2) COMMUNITY BASED PROGRAMS & SERVICES SECTION 3) HOSPITAL SERVICES SECTION 4) MEDICARE AND MEDICAL PROGRAMS SECTION 5) PHARMACARE SECTION 6) PUBLIC HEALTH
SECTION 3 – HOSPITAL SERVICES Prince Edward Island is home to seven hospitals. There are two main referral hospitals, the Queen Elizabeth Hospital and Prince County Hospital, based in Charlottetown and Summerside that provide a range of in- patient, out-patient, community and specialty services. Four community hospitals: Souris Hospital, Kings County Memorial Hospital, Community Hospital O'Leary and Western Hospital, provide a range of services which vary between facilities, including acute care, extended care and community-based services. The Island’s provincial in-patient psychiatric facility, Hillsborough Hospital, is located in Charlottetown.
PEI hospitals are a vital part of the integrated health system on the Island.
Primary Series Title SECTION 3: HOSPITAL SERVICES
3.1 HOSPITAL SERVICES
3.1.1 HOSPITAL SERVICES -GENERAL
3.1.2 HEALTH RECORDS
3.1.3 HEALTH CARE DIRECTIVES
3.1.4 OUT OF PROVINCE LIAISON PROGRAM
3.1.5 VOLUNTEER
3.2 AMBULANCE SERVICES
3.2.1 AMBULANCE SERVICES - GENERAL
3.2.2 AMBULANCE SERVICES - AIR
3.2.3 AMBULANCE SERVICES - GROUND-GENERAL
3.2.4 AMBULANCE SERVICES - GROUND-EMERGENCY MEDICAL SERV. BOARD
3.3 BLOOD SERVICES
3.3.1 BLOOD SERVICES - GENERAL
3.3.2 CANADIAN BLOOD SERVICES -
3.3.3 CANADIAN BLOOD AGENCY (CLOSED SERIES)
3.3.4 SETTLEMENT AGREEMENT - HEP C
3.3.5 THE CANADIAN RED CROSS SOCIETY (CRCS)
3.3.6 KREVER INQUIRY
3.3.7 TRANSFUSION - BLOOD
3.3.8 TRANSFUSION SERVICES - LABORATORY MEDICINE
3.4 DIAGNOSTIC IMAGING PROGRAM
3.4.1 DIAGNOSTIC IMAGING PROGRAM-GENERAL
3.4.2 DIAGNOSTIC IMAGING PROGRAM -CLIENTS
3.4.2 DIAGNOSTIC IMAGING PROGRAM-RADIATION SAFETY PROGRAM
3.4.3 DIAGNOSTIC IMAGING PROGRAM-NUCLEAR SAFETY PROGRAM
3.5 LABORATORY SERVICES
3.5.1 LABORATORY SERVICES - GENERAL
3.5.2 AUTOPSY PATHOLOGY
3.5.3 CYTOPATHOLOGY
3.5.4 SURGICAL PATHOLOGY
3.6.1 CLINICAL LABORATORY-GENERAL 3.6.2 CLINICAL LABORATORY- PATIENT RECORDS 3.6.3 CLINICAL LABORATORY- SPECIMEN DIAGNOSTIC MATERIAL 3.6.4 CLINICAL LABORATORY- ADMINISTRATIVE LAB FILES 3.7 STERILIZATION RECORDS 3.8 CANCER TREATMENT PROGRAM 3.8.4 CANCER TREATMENT CENTER – GENERAL 3.9 HUMAN HEALTH RESEARCH 3.9.1 PEI RESEARCH ETHICS BOARD
2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.1.1 HOSPITAL SERVICES - GENERAL This series deals with a wide range of Services/Programs/Issues relating to Hospital Services in the Province, including: staffing, services, costs, availability, etc., and are not found elsewhere in this series. Records date from the mid-1990s to present. A SA FD 20 Functional Planning Files AP+2y 20y SR 30 Special Projects AP+2y 10y SR 20: AP means until the plan is completed or rejected. 30: AP means until project is completed or terminated.
20- Hospital Services - Functional Planning Functional Planning pertains to structural design and/or redesign, interaction between the various departments of the hospitals or care facility and pertain in most cases to renovations of a facility. This process encompasses all aspects of the planning process: from the time a decision is made, to investigation of facility renovation/redesign, until the project is completed. This series does not include records relating to the physical construction of the facility. These records include Executive Council and Treasury Board Documents pertaining to the Functional Planning; Correspondence of the Steering Committee and Department/ Health Authorities, etc.; Analysis of space requirements; Workflow analysis; Physical environment analysis; Equipment analysis; Functional integration review; Services Committee documents (minutes, recommendations, decisions, etc.); Review of healthcare services provided/required; and Physical plan concept. Functional Planning has been carried out for O’Leary Community Hospital, Alberton Western Hospital, Atlantic Veterinary College at UPEI, Charlottetown Region Facilities, Kings County Facility Audit, QEH Heliport.
30- Hospital Services - Special Projects Hospital Special Projects are normally major, one-time equipment or service requirements which require substantial research, investigation and investment. The projects are a collaboration between the Department and Provincial Health Services Authority and/or Health Regions. Records date from the mid 1990s to present. Project Records: Includes analysis of staff and equipment utilization and requirements; Committee Records (agendas, minutes, background material, recommendations, decisions); Impact Analysis; Functional Plan; etc. Sample Projects include: Linear Accelerator (Project implemented to expand the range of services provided at the PEI Cancer Treatment Centre); Magnetic Resonance Imaging (Implementation of a diagnostic imaging service for the QEH); Bone Mineral Densitometry (screening test used to measure bone density); Echocardiology; and Transrectal Ultrasound.
2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.1.2 HEALTH RECORDS -In Patient (IP)
Acute Care is defined as the period of time or pattern of specialized health care during which a patient is treated, usually in a hospital, for a severe injury or illness, trauma or during recovery time from surgery.
Provincial Hospitals include: Queen Elizabeth Hospital, Prince County Hospital, Hillsborough Hospital.
Community Hospitals include: Western Hospital, Community Hospital, Stewart Memorial Hospital, Souris Hospital, King’s County Memorial Hospital.
A Health Record is defined as any written, printed, photographic or electronic record pertaining to a patient and may contain records in support of diagnosis, assessment, and treatment within the services of Inpatients, Ambulatory Care and Emergency at Provincial and Community Hospitals. Retention and Disposition Schedule A SA FD 20 Health Record -IP (Adult & Child) AOM + 20y* 0y Destroy 21 Health Record -IP-Microfilm/Microfiche AOM + 20y 0y Destroy 22 Health Record -IP- Deceased 3y 4y Destroy 23 Health Record - IP-Non-Resident Outpatient Record 5y AOM+10y Destroy 24 Health Record - IP-Fetal Monitor Strip 1y 37y Destroy 20: * Health PEI Legal Counsel has advised that if a Health Record is microfilmed and verified, the microfilm will become the legal record and the hardcopy could be destroyed). 20- Health Record: A health record includes patient identification, final diagnosis, consents, reports of diagnostic and treatment procedures, consultation reports, surgical reports, progress notes, orders for treatment, nurse’s notes, discharge summary, signature of attending physician, and anaesthetic records. A health records may also include strips and tracings, photographs, psychological and psychiatric assessments, correspondence, allied health professional’s reports and assessments; measurements of temperature, blood pressure, pulse rate and respiration rate, fluid balance, any other notes made by any health care professional who is providing care to a patient, and any note or communication from the patient. 21- Health Records - Microfilm/Microfiche: A film on which paper documents are photographed at a reduced size for ease of storage. 22- Health Record - Deceased –Once a patient or former patient has died, their chart is flagged as deceased. This event supercedes the retention period in sections 20 and 21. 23- Health Records - Non-Resident Outpatient Records - A non-resident refers to an individual who ordinarily resides outside of Prince Edward Island or Canada. 24- Fetal Monitor Strips: An electronic recording that monitors fetal heartbeats and the mother`s uterine contractions during pregnancy. The typical fetal monitor strip consists of two rows of graphs; the upper graph charting the fetal heart rate (in beats per minute) and the low graph charting the mother`s contractions.
5 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.1.3 HEALTH CARE DIRECTIVES Health Care Directives assist Islanders in health care planning and decision making; support individuals in creating health care directives; and identify health practitioners’ responsibilities for obtaining consent. Included in this series are: Health Care Directives; Consent to Treatment; Organ & Tissue Donation, etc. Records date from 1995 to present
Retention and Disposition Schedule A SA FD 20 Information Materials-Development Cy+1y 2y D 21 Information Materials-Final Product AP 4y SR 30 Health Care Directive Form-Hardcopy AP 4y SR 31 Health Care Directive Form -Electronic AP 0y D 40 Consent to Treatment-Capacity Assessors-Designated List AP+5y 0y D 41 Capacity Assessors- Training/Presentations S/O 0y D 50 Human Tissue Donation-Organ Donation Form 0y 0y D 21: AP means as long as the materials are being used, until revised or obsolete. 30-31: AP means as long as the forms are being used, until revised. 40: AP means until updated 41: S/O means until materials are superceded or obsolete.
20- Information Materials: Information Materials are developed to ensure Islander’s awareness of health care directive options available to them. These may be in the form of brochures, guidebooks, videos, etc. and include consultative development materials as well as the final product. Not all materials were approved for distribution. Samples of information materials that are/have been produced include: Video and script for video; several brochures (development and final product);and Islanders Guide to Consent to Treatment; Physicians Guide to Determining Capacity; etc.
30- Health Care Directive Form: A template Health Care Directives form was developed to assist Islanders in health care planning and decision making; to support individuals in creating their health care directive. These completed forms are retained by the individual, or the individual may decide to provide copies to another individual or to the hospital for inclusion in their medical record. Records include the development and final product of various forms, including the Health Care Directive form (a sample which individuals may chose to use), as well as copies of forms which have been developed for use by facilities.
6 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
40- Consent to Treatment - Capacity Assessors Pursuant to the Consent to Treatment and Health Care Directives Act, where a person has been assessed by a health practitioner and found to be incapable with respect to giving a valid consent for treatment, the person is advised of their right to a reassessment and may request this process to take place. Capacity Assessors (health practitioners as defined in the Act and who have completed the training program) conducting a reassessment will: consider the criteria for assessment of capacity; utilize the approved assessment tool (currently the Aid to Capacity Evaluation); review the assessment of the first health practitioner; inform the person and health practitioner of findings; inform the substitute decision-maker, next of kin, and/or associate where appropriate; and document findings on the Reassessment of Capacity form. Regions identify a health practitioner(s) to be designated as a Capacity Assessor. These individuals are provided training in order to carry out this role. Designates must participate in annual courses once initial training has been completed. Records date from 2000 to present. Designation List: Includes: name, work location, phone number, dates of training/refresher course.
41- Capacity Assessors: Training/Presentations: Training for Capacity Assessment includes: Role of capacity assessors; review of assessment of capacity, using assessment tool; and case studies. Materials provided for this training is primarily presentation materials or handouts.
50- Human Tissue Donation - Organ Donation Forms: (Closed Series) The Human Tissue and Donation Act states that hospitals must record whether or not Organ Donation was discussed with patients when death is imminent. Physicians complete the form, and the original is put in the patient’s file. A copy was sent to the Department from 1995 to 2000, at which time the process was changed and the Department was no longer sent a copy. The original is still maintained in the patient’s file. Forms: The form includes: Patient name, date of birth, provincial health number, gender, hospital, date of death, if donation was discussed, reason for not discussing donation, decision by consenting person, hospital personnel signature.
7 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.1.4 OUT-OF-PROVINCE LIAISON PROGRAM
The Out-of-Province Liaison Program was established to provide PEI patients and their families who must travel out- of-province for medical treatment with a resource to contact concerning their care. The program provides: assistance to PEI patients and their families who must receive health care services out-of-province; a linkage to health care professionals on behalf of PEI patients and their health care needs; and assistance with discharge planning needs of PEI patients. Patients/family members will contact the Department to inquire what services/assistance is available to them under this program. According to policies, inquiries are handled on a case- by-case basis. Records date from 1993 to present.
Retention and Disposition Schedule A SA FD 20 Client Records AP+2y 8y D 30 OOP Nurse Client Notes Cy+2y 8y D 40 Quarterly-Annual Reports Cy+2Y 8Y SR 50 Billings to NB Department of Health Fy+1y 6y D 51 Billing Information AP 0y D 20: AP means since date of last activity on the file. 51: AP means until Billing Information is revised.
20- Client Records: Includes applications, including the client’s name, address, phone number, provincial health number, hospital being referred to, conditions, treatment dates, number of treatments approved for payment, and the physician’s name, signature and date signed.
30- OOP Nurse Client Notes: These are notes completed by the out-of-province Liaison Nurse (in Halifax) on the transfer/coordination of sending patients back to PEI. Includes patient’s name, date, notes to ensure bed/required equipment is available for patient upon return and during transportation.
40- Quarterly/Annual Reports: Department has 2 full-time and 2 part-time out-of-province liaison nurses in Halifax. One position is designated to deal with N.B. patients under an agreement between PEI and NB, other nurse is designated to the PEI Out-Of-Province Liaison Program. Both are required to submit quarterly and annual reports detailing statistical information with regards to patients in out of province hospitals. Quarterly Reports: completed by the Liaison Nurse and includes: # of transfers, # of births, # of deaths, # of transplants, # of in-patient surgeries, # of out-patient surgeries; # of admissions; # of patients re-admitted to PEI hospitals; # of patients referred to Home Care/Public Health. Report includes the nurse’s report on services received by patients out of province, synopsis of office happenings, patient transfer data including personal information. Quarterly Reports includes client data on the N.B. residents - this information is separated and forwarded to N.B. Dept. of Health. Annual Report is a compilation of the quarterly reports, however may not contain some of detail contained in the quarterly reports.
8 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
50- Billings to New Brunswick Department of Health: The Department has two full-time, and two part-time out-of-province liaison nurses working in Halifax. One of these nurse positions is designated (full-time) to deal with New Brunswick patients under an agreement between PEI and NB. Information and billings are prepared quarterly to recover our costs for providing this service to NB. Records date from 1993 to present. Records includes bill (plus specific backup for billed amounts), copies of paid invoices (i.e. rent, photocopier costs), and FIS printouts of items billed directly to program funding (i.e. phone bill).
51- Billing Information: Includes percentage of staff time and benefits to be charged and calculation method.
9 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.1.5 VOLUNTEER
The acute care and long term care health facilities across Prince Edward Island have volunteers who generously donate their time to assist the Department of Health in fulfilling its mission.
Volunteer Services within the various Department of Health facilities are responsible for recruiting, selecting, training, placing, supervising and recognizing volunteers at various health facilities. Every effort is made to match volunteers with assignments that best reflect their interests, skills and needs as well as the needs of the health facility.
Retention and Disposition Schedule
A SA FD
20 Volunteer Applications - Denied 2 year 0y Destroy 21 Volunteer Applications - Pending 3 year 0y Destroy 30 Volunteer Record AP+1y 6y Destroy 40 Community Student Bursary AP+1y 6y Destroy 30: AP means until the volunteer terminates their service with the health facility 40: AP means until date of issue of bursary to post-secondary institution.
20- Volunteer Applications Denied - Applicants who have not satisfied the criteria established for becoming a volunteer (i.e. failed criminal back ground check, language incompetency)
21- Volunteer Applications Pending - Potential volunteers who have made application to volunteer but who have not proceeded through the interview and screening process.
30- Volunteers: Volunteers working within the Department of Health will assist staff with the care and comfort of patients. Volunteers complement the endeavors of staff in the delivery of comprehensive health care and are a central part of the health care team. These individuals provide a valuable link between the community and the health care facility, and they also fill a valuable public relations role. Volunteers do not perform the functions of paid staff. Volunteer placements are in numerous areas of Department of Health facilities.
40- Community Service Bursary : Island Students in grades 11 and 12, who plan to attend a post-secondary institution, are eligible for a Community Service Bursary. Students may begin volunteering as soon as they are promoted to grade 11. The bursary is calculated at a rate of $5 per hour. Students are required to volunteer a minimum of 30 hours or up to a maximum of 100 hours. (100 hours x $5 = $500 bursary) A Community Service Bursary is valid for up to one year following graduation from high school. Students may earn volunteer hours until August 31 of their graduation year. Bursaries will be issued to the student’s post- secondary institution in late November and will be applied to the student’s account.
10 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.2.1 AMBULANCE SERVICES - GENERAL
This series includes Ambulance Services records which are not found elsewhere in this Section.
Retention and Disposition Schedule A SA FD 20 Medical Transport Program - Invoices Fy+1y 6y D
20- Medical Transport Program: The Medical Transport Support Program was set up to provide support to Island Residents who are required by physicians to use ground ambulance services to access specialized medical services out-of-province. Invoices are submitted by ambulance companies for payment under this program. The patient is responsible for a pre-set user fee (currently $130), and the balance is paid by the program upon submission of eligible invoices. Records date from 2000 to present. Invoice Files: Includes the original invoice from ambulance operators for services provided. This information is compiled and summarized (without identifying patient information) and submitted for payment.
11 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.2.2 AMBULANCE SERVICES- AIR
Air Ambulance Services involve emergency air evacuation services which are contracted/ purchased from New Brunswick Air Care and Nova Scotia Emergency Health Services. This is a comprehensive service provided only when patients meet criteria for critical transfer. Records date from mid-1990s to present.
Retention and Disposition Schedule A SA FD 20 Company Information Cy+1y 0y Destroy 30 Transfer Forms/Incident Reports Cy+1y 6y Destroy
20- Air Ambulance Company Information: Includes correspondence with Air Ambulance companies, company information/brochures, business reports, quarterly reports, etc.
30- Transfer Forms/Incident Reports: Transfer forms are completed by the Air Ambulance company and sent to the Department for payment. A copy of the form also goes to the hospital for inclusion in the patient file. These forms are used by the Department to ensure proper care was provided during transport; to pay the ambulance company for services provided; and to compile statistics on usage. Information on the Transfer Form/Incident Reports includes: Patient name, address, phone number, date of birth, gender, weight, provincial health number; referring facility, location/unit; referring physician, contact number; receiving facility, location/unit; receiving physician, contact number; current diagnosis; major medical history; current medications; IV fluid, site, rate, medication, dose; room air/oxygen; monitoring requirements, recent vitals; completed by; date; flight information.
12 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.2.3 AMBULANCE SERVICES - GROUND Ground Ambulance operates 24 hours a day/7 days per week providing pre-hospital emergency services and hospital-to-hospital transportation services to patients requiring services in another hospital. Services are provided by five private operators who are subsidized through the PEI Ambulance Assistance Program. Retention and Disposition Schedule A SA FD 20 Incident Reports Cy+2y 5y D 30 Customer Satisfaction Surveys-General Cy+1y 0y D 31 Customer Satisfaction Surveys -Listings AP 0y D 32 Customer Satisfaction Surveys-Data AP+1y 0y D 33 Customer Satisfaction Surveys-Reports Cy+10y 0y SR 40 Call Sheets (Trip Sheets) Cy 7y D 41 Refusal Form Cy 7y D 42 Ambulance Information System Database-Development- Hardcopy AP 0y D 43 Ambulance Information System Database-User Information - Hardcopy AP 7y D 44 Ambulance Information System Database (Current) - Electronic C 7y D 45 Ambulance Information System Database (Old - 1998-2002) 7Y 0Y D 46 Call Sheet Reports Cy+1y 7y SR 47 Medical Audit Reports Cy+1y 7y SR 50 Program Reviews - Administrative AP+1y 4y SR 51 Program Reviews-Data Collection Tools AP+1y 4y SR 52 Program Reviews-Data AP 5y D 53 Program Reviews-Reports 10y 0y SR 60 Ambulance Operators-Permit Standards/Requirements AP+2y 4y SR 61 Ambulance Operators Files AP 7y D 62 Ambulance Operator-Monthly Wage Disbursement Reporting Form Fy+1y 6y D 70 EMT Licensing Standards/Requirements AP+2y 4y SR 71 EMT Listing AP 0y D 72 EMT File-Approved AP+1y 3y D 73 EMT Files-Rejected/Withdrawn 1y 3y D 42-43: AP means as long as administratively useful or until updated. 44: C means continuously updated for the duration of the database. 50- 52:AP means until Report is completed. 60-70: AP means as long as standards/requirements are in effect, until revised 61: AP means as long as ambulance company is in business (under the same owner). 71: AP means until updated 72: AP means as long as individual is licensed
13 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
20- Incident Reports: Incident Reports are prepared by the EMT or Operator anytime there is a failure to carry out a call. This may be due to vehicle failure, human failure, an accident, etc., which results in having another ambulance called out to replace the original ambulance. Information includes Company name, Vehicle, Reported by, Date, type, Time, Driver/Attendant, Others Involved, Details of incident, Details of Action Taken, Signature, Date Signed. Records date from 2001 to present.
30- Customer Satisfaction Surveys: Surveys are carried out as part of the Contract with Ambulance Companies (i.e. Customer Satisfaction Survey), or may be carried out to investigate possible improvements to the service. Records include: (a) General: includes copy of blank questionnaire form and form letter sent to clients; (b) Random Sample Listing - a random selection listing of a percentage of ambulance users, by company, over the past year. Includes client name, address, provincial health number and ambulance company used. List is used to mail survey questionnaires out; (c) Data/Completed Questionnaires - Includes provider used, date, specific questions where client stated satisfaction level with service received; and any addition comments the client added; (d) Reports: Report on satisfaction/dissatisfaction levels for various service questions (i.e. arrive on time, privacy was respected, staff was courteous, etc.). Includes themes on comments, and any Conclusions drawn from the Survey (may include recommendations, things that were well done). Qualitative data on each specific company is compiled separately, including direct quotes (good and bad) from completed questionnaires - these are provided to only the company it pertains to. Records date from 2001 to present.
40- Call Sheets (Trip Sheets): To ensure that ambulance services are carried out in a timely and effective manner, completion of call sheets are a requirement of both legislation and our contract agreement with each ambulance company. The call sheet provides the Department with consistent, reliable data of services being performed. This record may also provide a legal record of any call, in the event of any dispute between the ambulance company and the patient. This series consists of one call sheet for each call an ambulance is sent out on. Information on the call sheet includes: Call Form Number (preprinted); Service Name (ambulance company name); Unit Vehicle Number; Driver Number; Attendant Number; Destination; Date of Call; Number of kilometres; Call location; Problem; Patient name, address, billing address, phone number, age, sex, health card number; Time call received; Time ambulance went out; Time arrived at scene; Time arrived at destination; Time back at base; Code out (rating level of call - determines if lights/siren needed); Type of call (emergency or regular transfer, cardiac/farm/traffic/home/ occupational); Vital signs; Treatment provided before arrival (i.e. CPR by public); Name of person who made the call; Patient’s chief complaint; Emergency procedures performed by the EMT; Attendant’s signature, Amount charges; Comments. Form is being revised and may contain additional information. Records date from 1998 to present
41- Refusal form: When an ambulance is called, and the person refuses treatment a Refusal Form will be completed. The EMT will identify which services (Assessment, Treatment, Transport) were provided and which services were refused. The form includes client name, address, date, EMT’s signature, and client’s signature (if obtainable). Forms will start to be used in late 2003 or 2004.
42- Ambulance Information System Database: These databases were developed to record information provided and manage/tabulate ambulance call sheets, in order to ensure province-wide documentation of ambulance services. It allows for monitoring of compliance in matters of procedure (Regulations, Contract), and compiling statistical information. A Paradox program was used from 1998 to 2002. A new, more user- friendly program began in January 2003. The information from the Call Sheet is input into the Ambulance Information System Database. Developmental records involving the creation of this database are also
14 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
included in this series, as well as user information on the use of the system and samples of reports that can be created. Records date from 1998 to present.
46- Call Sheet Reports: To ensure ambulance services are carried out in a timely and effective manner, completion of call sheets are a requirement of both legislation and our contract agreement with each ambulance company. The call sheet is input into an Ambulance Information System Database which provides the department with reports that: provide consistent data on services for statistical purposes, allow for the monitoring to ensure legislative compliance, verify that number of ambulance trips and number of ambulance trips input in to the system balance. Includes the following Call Sheet Reports: Monthly Data Entry Trip Report: information includes date; call sheet number, patient’s health number, age, call location code, destination location code, type of call (transfer, emergency), problem or complaint (transfer, seizure, etc.), distance, cost. Report is run for each ambulance company, and provides statistical information, as well as being used to verify that the number of trips made equals the number of tips entered into the database. Chute Report: information includes total number of calls, number of calls by type, time - either day or night, and day of week. A report is generated for each ambulance company, and is used to identify any calls where the ambulance did not reach the destination of an emergency within the required time frame (when this happens the company is notified, and may result in financial penalties). Exceeding Chute Time Reports: compiled pursuant to the performance contract. Information includes the number of emergency call-outs by company, calculation of non-acceptable time frames, where arrival time is not less than 5 minutes, 90% of the time - as calculated on a monthly basis. Records date from 1998 to present.
47- Medical Audit Reports: The Company Medical Advisor completes a report on a random sample of calls per month to assure integrity/policy/protocol is met. Medical Audit Report includes company name, date, month(s) being reviewed, total number of calls (emergency / non-emergency), review of calls, (i.e. were protocols followed, what were the deviations, reasons for deviations, if deviations were supported by medial advisor, recommendations if deviation is not supported, action plan); signature of medical advisor, signature of ambulance company owner.
50- Program Reviews/Studies: Reviews periodically take place, and may cover one area or the entire spectrum of Ambulance Services. Review may be conducted either internally or contracted to an external consultant. Reviews are conducted with a view to improving service. Reviews/Studies include: (a) Administrative/Planning records - created and kept to outline the Review/Study being carried out and keep track on the progress of the project. May include a Review Plan, including: process being undertaken, timelines, framework, presentations, correspondence, etc; (b) Data Collection Tools are created in order to collect the information required for the review/study. Records in this series include the final copy of the data collection tool (questionnaires, forms, check sheets, etc.). Other documentation that may be included in this series include: samples of other similar tools, working drafts, and documentation around how the tool was developed; (c) Data is collected to provide information on services provided, clients, service delivery, possible improvements, etc. Data includes all information on the completed data collection tools, and may be qualitative and/or quantitative; and (d) Reports. Once the review is complete, a final report on findings identifying the positive and negative program aspects and make recommendations. The reports are used by program staff to improve services to the public. Status Reports are prepared to review progress of the recommendations in reviews/studies. Records date from 1997 to present.
15 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
60- Ambulance Operators-Permits Standards & Requirements -: To operate an Ambulance Company on PEI, a permit must be obtained from the Emergency Medical Services Board. Permits are valid for 1 year, after which the operator must reapply for renewal. This series records the information required to apply for, and receive a permit. Standards & Requirements outline Roles, Responsibilities and Standards for permits to operate ambulance services. Records include correspondence, background information, vehicle specifications, equipment specifications, developed criteria and standards, and other requirements necessary for licensure; Contract performance standards; Equipment standards for ambulances; Inspection for ambulance company licensure; Inspection criteria for ambulances; Roles and Responsibilities for Ambulance Operators. Records date from the 1980s to present.
61- Ambulance Operator Files: Records in this series may include: Permit Application (includes company name, address, operator, ambulance listing, location information, insurance information, EMT staff numbers, medical advisor’s name, hours of operation for each vehicle); Business Plan; Vehicle Inspection; Insurance Policy; Medical Audit Report; Billing information; staff notes; Contingency plan for operations (what will happen if operator is unable to continue - who next operator will be, if ambulance is not working - what will be done/other ambulances that may cover off, in case of fire - alternate arrangements that have been made, etc.); correspondence between department and operator on various issues to do with operation (ie. Communication system, issues, audit schedules, etc.); Covering memo sent with permit; Copy of permit. May also include information on the purchase or sale of the ambulance company, ambulance, and/or equipment (mortgage, contract, indenture, funding documents), and proposals submitted. Records date from the 1980s to present.
62- Ambulance Operators -Monthly Wage Disbursement Reporting Form (Closed Series): As a condition of the prior contract (1998-2000) with ambulance operators, this form was required to monitor financial amounts provided to operators for employee wages. This assured the Department that funds that went to the operators for wages was spent on wages. Information includes: Ambulance operator; Month and year; Employee Name; Employee Number; Paramedic level; Employment status; number of hours worked; Hourly rate; Gross earnings; Employer contributions; Signature of person completing the form. Records date from 1998 to 2000.
70- Emergency Medical Technicians (EMT’s) Licensure Standards & Requirements: In order to work as an EMT for an Ambulance Company on PEI, individuals must obtain a license from the Emergency Medical Services Board. Licenses are valid for up to 2 years, after which they may be renewed. This series records the information required to apply for, and receive a license. Licensing Standards and Requirements outline the Training and Education requirements necessary for licensure. Records include correspondence, background information on Paramedic Education Programs, Continuing Education available; First Aid/CPR training. Records date from the 1990s to present.
71- EMT Listing: includes a listing of all EMTs licensed in the province - including their name, licensing level, license number, and employment status. Records date from the 1990s to present.
72- EMT Licensing File: Records in this series may include: Application Form, Applicable Appendices, Abstract of applicant’s drivers record, CPR certification, Paramedic/EMT diploma, copy of drivers license, letters of reference, resume, police certificate/search of criminal activity report, EMT call-out form (for re-licensure requirements applicant must have been out on a minimum # of calls during previous 3 years), proof of continuing education requirements, Letter of Licensure, Copy of License. Records date from the 1980s to present.
16 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.2.4 AMBULANCE SERVICES - GROUND - EMERGENCY MEDICAL SERVICES BOARD
The Emergency Medical Services Board was created in 2001 as a body corporate as a result of revisions in the Public Health Act and creation of the Emergency Medical Services Regulations. This Board is charged with responsibility of licensing ambulance companies and EMT’s. The purpose of the Board is to regulate the provision of emergency medical services in the province. The functions of the Board are to: (a) accept and assess applications and issue permits and licenses; (b) monitor adherence to prescribed standards by permitees and licensees; (c) make such policy and guidelines and approve such forms as the board considers necessary for the carrying out of its functions; (d) investigate and take remedial or disciplinary action as necessary in cases of alleged negligence, incompetence, misconduct, or non-compliance with prescribed standards; (e) advise the Minster and make recommendations for regulations respecting (i) standards for operating ambulances and providing ambulance services, (ii) qualifications for the licensing and standards for the practice of emergency medical technology, and (iii) any other matter concerning the provision of emergency medical services. Records date from 2001 to present.
Retention and Disposition Schedule A SA FD 20 Board Records Cy+2y 5y SR 30 Medical Director Records Cy+2y 5y SR 40 By-Laws AP+2y 5y SR 40: AP means as long as the By-Laws are in effect, until revised.
20- Board Records: Includes agendas, minutes, board membership, information on honoraria, background material on applications for licensure, and recommendations on operator and EMT applications.
30- Medical Director Records: The Medical Director is responsible for overseeing individual ambulance company medical advisors. Records include background information pertaining to this provincial role; and correspondence/documentation with providers, public, EMS Board, and the public on any issue he/ she may deal with.
40- By-Laws pertain to the EMS Board/Board Members, including appointment of officer(s), conflict of interest, renumeration, meetings, communication, confidentiality, amendments and repeals, and compliance.
17 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.3.1. BLOOD SERVICES - GENERAL This series includes records relating to Blood Services, and the security/safety of blood products and their use which are not found elsewhere in this Section. Records date from 1990 to present.
Retention and Disposition Schedule A SA FD 20 Lookback/Traceback Contribution Agreement AP+1y 50y SR 21 Lookback/Traceback - Listing of Individuals AP+1y 50y D 30 Undertaking Agreement AP+1y 50y SR 40 Deputy Ministers Steering Committee on Blood Cy+1y 50y SR
20-to 30: AP means for the duration of the Agreement
20- Lookback/Traceback Contribution Agreement: This agreement is between the Federal Minister of Health and the Province of Prince Edward Island, and outlines Initiative activities to be undertaken to identify and notify recipients of blood/blood products and are at risk of infection with Hepatitis C, the Reporting Framework, ad the Listing of Expenditures Incurred. Records include the Agreement, and a listing of individuals who were sent notification letters because they had receive blood during the designate period of time.
30- Undertaking Agreement: This is an agreement between Health Canada and each province on shared objectives (including improved access to health services for the treatment of Hepatitis C)and the terms under which transfer payments will be made (scheduled to take place until 2014-2015). Records include Undertaking Agreement, drafts, correspondence/comments to/from Health Canada and Provinces, drafts, briefing notes, meeting notes and minutes, staff notes, etc.
40- Deputy Ministers Steering Committee on Blood: This Committee was established to oversee various issues related to blood, reorganization, agreements, etc. Records include agendas, minutes, staff notes, correspondence with other provinces/federal government, statistical information, financial information, documents on Strategic Plans for the blood system, etc. Also includes records of Support Committee to the DMs Steering Committee on Blood.
18 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.3.2. CANADIAN BLOOD SERVICES
The Canadian Blood Services (CBS) is a not-for profit, charitable organization operating at arm’s length from government. Its mission is to manage the blood supply for Canadians. Created in 1998, it is the successor to the Canadian Red Cross Blood Program and the Canadian Blood Agency. In 1996 F/P/T Ministers of Health decided to establish a new National Blood Authority (NBA) to manage Canada’s blood system. The term NBA was used to describe the yet to be formed new blood agency which would become the Canadian Blood Services, and was designed to operate at arm’s length from all governments and be fully accountable for managing all aspects of an integrated blood supply. Transition to the new system was overseen by F/P/T Deputy Ministers of Health via a Transitions Steering Committee. An Implementation Team included F/P/T officials to work on key issues such as a master implementation plan, a business plan, legislative framework, and details concerning funding, reporting relationships and accountabilities. Special Advisors on Consumer, Medical and Technical Issues were appointed to advise the implementation team. The Memorandum of Understanding’s purpose is to record the understandings and commitments of the Minister of Health (Canada) and the Provincial and Territorial Ministers of Health regarding their respective role and responsibilities in a renewed national blood system, including their future relationships with the National Blood authority (CBS) and its function and structure. Records date from 1997 to present. Retention and Disposition Schedule A SA FD 00 National Policy-Standards AP+2y 50y SR 20 Canadian Blood Services Agreements AP+1y 50y SR 30 National Blood Authority - Transition Records: Cy+1y 50y SR 35 National Blood Authority- MOU AP+1y 50y SR 40 P/T Blood Contacts Meetings Cy+1y 20y SR 41 Working Groups Cy+1y 20y SR 50 Board of Directors Quarterly Report to Members Fy+2y 0y D
00: AP means as long as policy/standards are in effect. 20: AP means for the duration of the agreement 35: AP means as long as PEI is a Member of the Canadian Blood Services
00- National Policy / Standards: Records include National Policy and Standards for Blood Safety, and records related to the development.
20- Canadian Blood Services Agreements: Canadian Blood Services Agreements include: Indemnification Agreement, re CBS and all provinces; Waver of Subrogation Agreement re CBS and all provinces; and Que Memorandum of agreement re: Blood Lab Services. Records include the agreement and background materials leading up to development of the agreement.
30- National Blood Authority - Transition Records: NBA Transition Records - Includes correspondence/documents/etc between F/P/T representatives, legal representatives and the Canadian Blood Services Transition Bureau. Includes ECMs regarding the Acquisition Agreement (of Canadian Red 19 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
Cross Society) and the negotiation/transfer of assets; implementation, governance and incorporation of the National Blood Authority; and advice to Ministers about management options and financial options/costs.
35- National Blood Authority - Memorandum of Understanding: The NBA Memorandum of Understanding is a sets out the mandate, roles and responsibilities for the Members and the Board. Annexes to the MOU include: Annex A sets out the functions and responsibilities of the NBA/CBS; Annex B describes governance model; and Annex C addresses transition issues. Also includes in the records are the status reports and records of advice to Ministers in development of the MOU.
40- P/T Blood Contacts Meetings: CBS has a two-tiered governance structure: 1) the Corporate Members - Provincial/Territorial Ministers of Health; and 2) the CBS Board of Directors - Appointed by the Members to oversee the organization. In addition, each members identifies a contact person from their Ministry to serve as the day-to-day liaison with CBS - these are referred to as the P/T Contacts. Records date from 1998 to present. Meeting records include agendas, supporting documentation for each item, final budgets/financial records, minutes of the meetings, correspondence/e-mails relating to meetings or documents. Also included are the Corporate Plans, Business Plans, Membership/Contact Lists, and Reports.
41- Working Groups: Where additional work is required for the P/T Contacts, a working group will be struck. These working groups usually included members of the P/T Contacts as well as experts in a specific field (i.e. Blood Education, West Nile or Product Utilization). Records include agendas, minutes, supporting documents, recommendations.
50- Board of Directors Quarterly Report to Members: Quarterly Reports are prepared quarterly by the Board of Directors in order to report to the Members on the progress of the corporation. The Quarterly Report consists of a document which includes a Executive Summary, reports of major achievements, operations report, and financial statements/reports.
20 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.3.3 CANADIAN BLOOD AGENCY (CLOSED SERIES)
The Canadian Blood Agency (CBA) was created by Provincial/Territorial Ministers of Health in 1991 as a non-profit corporation, being funded by provincial and territorial governments. The Ministers of Health were members of the corporation, and appointed a Board of Directors which included representatives from each province. The mandate of the CBA was to “coordinate and finance the National Blood Supply Program in accordance with the Ministers of Health for the therapeutic use of human blood, blood products or their substitutes”; and also offered advice to the provincial/territorial Health Ministries about blood product funding policy. The Canadian Blood Agency continued with their responsibilities until there were assumed by Canadian Blood Services. Records date from 1990 to 2000. Retention and Disposition Schedule A SA FD 20 Financial Statements AP+1y 50y SR 30 Working Group Records AP+1y 50y SR 40 Presentations - Proposals AP+1y 50y SR 50 Blood Governance Initiative AP+1y 50y SR 60 Reviews AP+1y 50y SR 70 Board of Directors Meeting - Minutes AP+1y 50y SR 80 Background-Draft Documents AP 0y D 20 to 70: AP - means until the Canadian Blood Agency ceased to exist (2000) 80: AP means until the final documents have been prepared and circulated
20- Financial Statements: Records include Income & Expenditures per year 30- Working Group Records: This includes the Finance Committee and Working Group on National Elements related to CBS. Records include: minutes, agendas, financial statements, background/ reference material; etc. 40- Presentations/Proposals: Records include a proposal/presentation by Hemophilia Society; a presentation on Recombinant Factor VIII (a rare hereditary bleeding disorder); materials on safety hearings; and a Supply Agreement Proposal between the Canadian Red Cross and Canadian Blood Agency. 50- Blood Governance Initiative: This is Health Canada’s Governance Initiative - records include the report and correspondence. 60- Reviews: This is a file of the Review of the Organization and Management of the Blood System in Caranda, dated Sept. 30/95. 70- Board of Directors Meeting - Minutes: Records include a copy of the final agenda, supporting documentation for each item, final budgets/financial records, minutes of the meetings. Also included are Business/Corporate Plans for the Canadian Blood Agency which outline the organizations future direction; Board information and membership list; Board issues; and general information on the Indemnification for Board and Members Agreement. 80- Background/Draft Documents: These are transitory records: draft agendas, proposed budgets, and correspondence/e-mails relating to creation of the final documents. Final documents are included with Board Meeting Minutes.
21 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.3.4. SETTLEMENT AGREEMENT - HEP C In 1998 F/P/T Ministers of Health announced the creation of a fund to provide financial assistance to: Canadians infected with Hepatitis C (HCV) through blood transfusions or receipt of blood products in Canada between Jan. 1/86 and July 1/90; Canadians secondarily infected with HCV by a parent or partner infected during this period; and Persons secondarily infected with HIV through a parent or partner who contracted HIV through the blood system. In May 1999 a final proposed settlement agreement was reached by F/P/T governments and counsel for the plaintiffs. Records date from 1993 to present. Retention and Disposition Schedule A SA FD 20 Multi-Prov-Terr Assist. Program-Package (Hep C) AP+1y 50y SR 30 MOU - HEP C Settlement Agreement AP+1y 50y SR 40 Deputy Ministers Steering Committee AP+1y 50y SR 20: AP means until finalization of arrangements in the Assistance Package 30: AP means until the expiry of the MOU/Agreement 40: AP means for the duration of the Committee
20- Multi-Provincial Territorial Assistance Program/Package (Hep C Assistance/Compensation): Records in this series include: - Multi-Provincial Territorial Assistance Program/Package - Includes correspondence between Federal and Provincial/Territorial representatives, special interest groups (i.e. Hemophilia Society, Canadian Red Cross), and legal representatives regarding development, issues, implications, revisions, decisions on the Compensation Package - Hep C Assistance/Compensation - records include correspondence/presentations/articles between provinces/territories/federal government representatives, other interested parties (i.e. Hemophilia Society), legal representatives, the public, and the media relating to compensation through the Hepatitis C Settlement. - Notification Programs, including procedures to notify residents who received blood transfusion between 1984 and June 1, 1990 informing them that they are at risk of having hepatitis C - Income Exemption issues surrounding Hep C Compensation - documents relating to Income Tax Exemption for Settlement Award.
30- Memorandums of Understanding / Hep C Settlement Agreement: Records in this series include: - MOU (Canada/Provinces/Territories) - Cost Sharing relating to the Hepatitis C Settlement and the Federal/Provincial/Territorial Assistance Program for HIV Secondarily Infected persons. - 1986-1990 Hepatitis C Settlement: Settlement Agreement and Funding Agreement. Hepatitis C Settlement - legal summaries and briefings, Ministerial briefing notes, drafts, memos and decisions to/from Treasury Board and Executive Council; copy of Settlement Agreement. Includes implementation of the Agreement/Settlement Plan, including appointment of the Plan Administrator, provincial contributions to the fund, - MOU (Canada/Provinces/Territories) -Cost Sharing of Commercial insurance relating to the Op-outs of the 1986- 1990 Hepatitis C Settlement Agreement - includes correspondence and materials between Health Canada, Provinces/Territories and Insurance Company. - Working Group on financing the Hep C Settlement Agreement
40- Deputy Ministers Steering Committees: Records in this series include: - Deputy Ministers Steering Committee on Hep “C” - Includes correspondence/e-mail between provinces, agendas, records of discussion and decision, briefing material, summary notes and status updates., - Deputy Ministers Steering Committee on Hep “C” Litigation. Also includes documentation on Hep C legal and litigation Issues. Includes records of discussion and decisions, class action lawsuit documents, staff notes. Also includes records on the Working Group for Financing the Hep C Settlement, including Terms of Reference, Issues, agendas, records of discussion and decision, staff notes, trust fund options and fees, cost sharing arrangements. 22 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.3.5 THE CANADIAN RED CROSS SOCIETY (CRCS)
The Canadian Red Cross managed/coordinated Canada’s blood supply until responsibility was transferred to the National Blood Authority/Canadian Blood Services. Records in this series involve the CRCS’s future role in Canada.
Retention and Disposition Schedule A SA FD 20 Red Cross Materials Cy+1y 50y SR 30 Companies’ Creditors Act Claim & Plan of Comp. Cy+1y 50y SR 40 Release Agreement Cy+1y 50y SR
20- Red Cross Materials: Records include Canadian Red Cross Society Annual Reports; report of the Canadian Red Cross Fractionation Corporation; Communiques/Press Releases/Media; Promotional material on establishment of Plasma Collection Centre.
30- Companies’ Creditors Act Claim & Plan of Compromise and Arrangement: An arrangement which was made, under the protection of the court, to develop a way of meeting the claims of transfusion claimants and trade creditors arising from the years during which it operated the blood program. Records include the CRCS proposed plan of compromise and arrangement, Ontario Superior Court documents/orders, legal correspondence/records; correspondence with other provinces; etc.
40- Release Agreement: This is an agreement between the Federal/Provincial/Territorial Governments, Canadian Red Cross Society (CRCS), Dominion of Canada General Insurance Company, Commercial Union Assurance of Canada and the Canadian Blood Agency, whereby, the FPT Governments agree to deliver a direction to the Class members to release the CRCS from liability to the Class members on account of injuries sustained directly or indirectly as a result of treatment with blood or blood products according to the 1986-1990 HCV Settlement; the FPT Governments agree to seek the dismissal of the 1986-1990 class actions which are the subject of the 1986-1990 HCV Settlement against the Society; and the Society agrees to release and discharge the FPT Governments and the CBA of all claims made in the Indemnity Action - among other sections of the agreement. Records include a copy of the Agreement; correspondence with other provinces; legal reviews/documents; Ministerial briefings, staff notes, etc.
23 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.3.6 KREVER INQUIRY
In 1993 Justice Horace Krever was appointed to head a Royal Commission of Inquiry with the mandate to investigate the management and operation of the blood system in Canada, including the events surrounding the contamination of the blood system. After nearly four years of a public judicial inquiry, Justice Krever issued his report on November 26, 1997. Records date from 1995 to 2000
Retention and Disposition Schedule A SA FD 20 Reports Cy+1y 50y SR 30 Trial Documents Cy+1y 50y SR 40 Inquiry Documents Cy+1y 50y SR
20- Reports: Includes the following reports: - Interim and Final Report on the Commission of Inquiry on the Blood System in Canada (Krever), including recommendations for Canada’s blood system; - Response to Krever Inquiry Interim Report; - Krever Commission Notes; - Red Cross Response to Commission of Inquiry; - Status Report on F/P/T Responses to the Krever Commission Recommendations
30- Trial Documents: Records include: Federal Court Trail Decision; Transcript of the Commission of Inquiry; Appeal: Canadian Red Cross vs Krever
40- Inquiry Documents: Records include: 110 documents submitted on behalf of the Province of PEI. This includes provincial government correspondence, policy, information pamphlets, meeting notes, minutes, etc. on subjects such as AIDS, Hemophilia; Blood and Blood products; Fractionation Plant; Family Life Education, Blood Transfusions, etc. These documents summarized by Legal Services, the summary was submitted to the Inquiry, and documents were turned over to the Department at the end of the court case.
24 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.3.7. TRANSFUSIONS (BLOOD) The Department is involved with, and concerned about, blood transfusions primarily from a perspective of controlling communicable diseases. Records date from 1996 to present.
Retention and Disposition Schedule A SA FD 20 Committees - Working Groups Cy+3y 10y SR
20- Committees/ Working Groups: The Provincial Blood Transfusion Committee’s mandate is to bring together those individuals (organizations) who play a major role in blood transfusions in the province - Department, Regions, Hospitals, Canadian Blood Services. This committee was struck with the creation of the Canadian Blood Services and is required under national regulations. The committee discussed provincial blood issues such testing and reporting for West Nile Virus, HIV/AIDS, and Hep C. Working Groups, such as the Surveillance and Epidemiology in Transfusion Working Group may be struck. Records include agendas, minutes, records of decision, terms of reference, national information, etc.
25 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.3.8 TRANSFUSION SERVICES - LABORATORY MEDICINE On May 25, 2001, a Licensing Agreement was made between Canadian Blood Services and Queens Region Health and Community Services (now Health PEI). Responsibility for the operation of the Blood Centre, formerly operated by Canadian Blood Services, was assumed by PEI Transfusion Services. This Licensing Agreement included the transfer of records dating back to 1982.
PEI Transfusion Services is responsible for the receipt of any unit of blood, component, tissue, or derivative from its source to final disposition and includes laboratory services at Provincial and Community Hospitals. The records systems established in these facilities provide a means to locate and access all records related to a given unit of blood or blood component making it possible to trace a blood product from its source to its final disposition (i.e., transfusion, further manufacturing, or destruction). PEI Transfusion Services records include serious transfusion event records, look back/trace back documents, blood supplier documentation, recipient type records, and screen results.
Canadian Blood Services dictates the minimum guidelines for retention of all Blood Transfusion Services records as set out in the Canadian Standards Association Blood and blood Components Standards for Blood Banks and Transfusion Services 24th Edition.
Retention and Disposition Schedule Patient Records A SA FD 20-1 Dispense Vouchers Cy+2y 97y D 20-2 Compatibility Tags (top portion) Cy+2y 97y D 20-3 Serious Transfusion Event Record Cy+2y 97y D 20-4 Clinically Significant Antibodies Record Cy+2y 97y D 20-5 Requisitions Cy+1y 8y D 20-6 Adverse Transfusion Event Record Cy+1y 3y D 20-7 Autologous Donors Record Cy+1y 3y D 20-8 PEI Prenatal Worksheets Cy+1y 3y D 20-9 28 Week RH Immune Globulin Sheets Cy+1y 0y D
20- Patient Records Records in this series document the transfusion of a blood product to a patient. These records contain patient information documenting: the blood product used, whom it was transfused to, date and time it was transfused, and the results of that transfusion. Records in this series also include: the request from the physician for a transfusion; a transfusion by a patient for themselves (autologous); and Rh testing and record of RH globulin units given to Rh positive pregnant women.
26 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
20-1 Dispense Vouchers – record of issued blood products to the patient.
20-2 Compatibility Tags – top portion - confirmation sheet of transfused product to patient
20-3 Serious Transfusion Event Record– occurs when a patient has a significant reaction to a blood product he/she received. This is considered a serious event that may cause harm to the recipient.
20-4 Clinically Significant Antibodies Record– records proteins produced by an individual that can cause serious transfusion reactions when blood with the corresponding antigen is received. Breakdown of red blood cells can occur.
20-5 Requisitions – requests for blood transfusion testing
20-6 Adverse Transfusion Event Record– documentation recording date and time when something goes wrong during a blood transfusion. This is considered to be a non-serious event such as a short term raise in temperature.
20-7 Adverse Transfusion Event Record– documentation recording date and time when something goes wrong during a blood transfusion. This is considered to be a non-serious event such as a short term raise in temperature.
20-8 PEI Prenatal Worksheets – worksheets which record the date and time of the testing of pregnant women for their Rh status and unexpected antibodies.
20-9 28 Week RH Immune Globulin Sheets – records recording date and time of blood product that is given to Rh Negative pregnant women to prevent them from forming one type of antibody which could seriously harm their baby.
*As per Canadian Standards Association (Z902-10) A National Standard, these records are to be kept indefinitely. No records are to be destroyed without the approval of Transfusion Services. At the end of the 97y period, Transfusion services will be consulted and a decision will be made whether to return records to storage or to destroy them.
27 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
30. Lab Administrative Files This record series documents the procedures used in a laboratory to ensure the blood product is properly received and stored until its final disposition. This series also documents the employee who was responsible for the transfusion, as well as monitoring and testing of equipment. These records are used to ensure proper specifications are met as set out in the Canadian Standards Association Blood and blood Components Standards for Blood Banks and Transfusion Services 24th Edition. Retention and Disposition Schedule Lab Administrative Files A SA FD 30-1 Blood Component Receipt Vouchers Cy+2y 97y D 30-2 Plasma Protein Receipt Vouchers Cy+2y 97y D 30-3 Blood Component Product Recall Disposition Reports Cy+2y 97y D 30-4 Look Back / Trace Back Files Cy+2y 97y D 30-5 Archived Operating Procedures Cy+2y 97y D 30-6 Records of Employee signatures, ID initials 10y 0y D 30-7 Work Units Cy+1y 8y D 30-8 Temperature Charts Cy+1y 8y D 30-9 Temperature Monitor and Shipping Log Binder Cy+1y 3y D 30-10 Compatibility Tags – bottom portion Cy+1y 3y D 30-11 Reagent Preparation Worksheet Cy+1y 3y D 30-12 Proficiency Testing Records Cy+1y 3y D 30-13 QC Forms (F501A, F501B, F501C, RGT.OO2) Cy+1y 3y D 30-14 Visual Inspection of Blood Components Record Cy+1y 3y D 30-15 Master Anagram Panel Ortho, Gamma, BCA Records Cy+1y 3y D 30-16 Cleaning Maintenance Binder Cy+1y 3y D 30-17 Micro Typing System Binder (Ortho) Cy+1y 3y D 30-18 Reagent Red Cell Extended Panel Typing + Prep worksheet Cy+1y 3y D 30-19 CAP Survey Results Records Cy+1y 3y D 30-20 Pipette Volume Verification Records- Cy+1y 3y D 30-21 Rejected Specimens Records 1y 0y D 30-22 Return Voucher for Blood Products Records 1y 0y D 30-23 Blood Component/Platelet Order/Receipt Binder 1y 0y D 30-24 Daily Blood Inventory 1y 0y D 30-25 Administration Checklist 1y 0y D
28 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
30-1 Blood Component Receipt Vouchers - record of blood products received from Canadian Blood Services (CBS). 30-2 Plasma Protein Receipt Vouchers – record of blood products, which have undergone a manufacturing process, received from CBS. 30-3 Blood Component Product Recall Disposition Reports – record of any blood product recalls from CBS. 30-4 Look Back / Trace Back Files – a record of a blood product from the time that it is donated to the time it is transfused or disposed of. 30-5 Archived Operating Procedures – documents procedures that are no longer performed 30-6 Records of Employee signatures, ID initials 30-7 Work Units – records a measure of work flow 30-8 Temperature Charts – documents that record the temperature of all fridges and freezers 24 hours a day. 30-9 Temperature Monitor and Shipping Log Binder – record of daily outdoor temperature which is required for the shipping of blood products to outside hospitals. 30-10 Compatibility Tags – bottom portion –documentation confirming delivery by porter. 30-11 Reagent Preparation Worksheet – documentation of chemicals prepared “in house” which meet or exceed FDA criteria. 30-12 Proficiency Testing Records (Self Check, Gamma, Teck Check) – documentation used to assess Laboratory Technologists skill and knowledge. 30-13 QC Forms (F501A, F501B, F501C, RGT.OO2) – Quality Control Forms. 30-14 Visual Inspection of Blood Components Record– documentation recording date and time of regularly performed inspection to ensure quality of inventory. 30-15 Master Anagram Panel Ortho, Gamma, BCA Records- documents used to help identify and record unexpected antibodies. 30-16 Cleaning Maintenance Binder – record of cleaning lab equipment 30-17 Micro Typing System Binder (Ortho) – a binder which documents a method of Laboratory Testing. 30-18 Reagent Red Cell Extended Panel Typing and Preparation Worksheets – worksheets used in identifying antibodies which are atypical in behavior or rare antibodies. 30-19 CAP (College of American Pathologists) Survey Results Records -The surveys help to monitor Lab Techs skill, knowledge, and performance. 30-20 Pipette Volume Verification Records- ensures accurate and precise volume delivery of small amounts of liquid. 30-21 Rejected Specimens Records – records when blood specimens are collected while not adhering to specimen collection protocol. 30-22 Return Voucher for Blood Products Records – record from outside hospitals that blood products were received. 30-23 Blood Component/Platelet Order/Receipt Binder – a record of blood products ordered and received from CBS.
29 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
30-24 Daily Blood Inventory – inventory of red bloods cells available.
30-25 Administration Checklist – record of non-technical duties which need to be performed every day.
As per Canadian Standards Association (Z902-10) A National Standard, these records are to be kept indefinitely. No records are to be destroyed without the approval of Transfusion Services. At the end of the 97y period, Transfusion services will be consulted and a decision will be made whether to return records to storage or to destroy them.
Rationale – Canadian Standards Association Blood and blood Components Standards for Blood Banks and Transfusion Services 24th Edition Hospital Acts H-10-1 Canadian Blood Services and Queens Region Health and Community Services Licensing Agreement
30 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.4.1 DIAGNOSTIC IMAGING - GENERAL
The Provincial Diagnostic Imaging Program provides a complete range of diagnostic treatment services to patients across Prince Edward Island. Diagnostic Imaging services are delivered at the Queen Elizabeth Hospital, Prince County Hospital and the five community hospitals (Souris Hospital, Kings County Memorial Hospital, Western Hospital, Stewart Memorial Hospital, and Community Hospital O’Leary).
Diagnostic Imaging creates visual representations of the interior of a body for clinical analysis and medical intervention. Diagnostic Imaging seeks to reveal internal structures hidden by the skin and bones, as well as to diagnose and treat disease.
The modalities provided in DI include general radiography, bone mineral densitometry, fluoroscopy, nuclear medicine, ultrasound, mammography, special procedures, CT and MRI.
General Radiography: Conventional radiography refers to a broad range of diagnostic imaging tests and is the basic form of medical imaging. X-rays are used to create images of the body’s internal structure.
Bone Mineral Densitometry: Bone density scan is an enhanced form of x-ray technology that is used to measure bone loss.
Fluoroscopy: Fluoroscopy is a form of diagnostic radiology that enables the radiologist, with the aid of a contrast agent, to visualize the organ or area of concern via x-ray. This contrast agent allows the image to be viewed clearly on a television monitor or screen. Contrast agents (or "contrast media" as they are also known) may be introduced into the body through injection, swallowing or an enema. Examples include: • Barium Swallow • Upper GI Series • Small Bowel Series • Barium Enema • Hystersalpingogram - special procedures • Intravenous Pyelography - under general Voiding Cystourethregram - special procedure • Myelography -CT/MRI • Arthrogram -MRI • Biopsy
Nuclear Medicine: Nuclear medicine is a medical specialty that uses safe, painless, and cost effective techniques both to image the body and treat disease. Nuclear medicine imaging is unique in that it documents organ function and structure, in contrast to diagnostic radiology, which is based upon anatomy.
31 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
Ultrasound: Ultrasound (US) imaging, also called ultrasound scanning or sonography, is a method of "seeing" inside the human body through the use of high-frequency sound waves. The sound waves are recorded and displayed as a real-time visual image. No radiation is involved in ultrasound imaging.
CT (Computed Tomography): CT (computed tomography), sometimes called CAT scan, uses special x-ray equipment to obtain image data from different angles around the body, and then uses computer processing of the information to show a cross-section of body tissues and organs.
MRI (Magnetic Resonance Imaging): MRI is a non-invasive procedure that uses powerful magnets and radio waves to construct pictures of the body. MRI imaging is based on the magnetic properties of atoms. A powerful magnet generates a magnetic field roughly 10,000 times stronger than the natural background magnetism from the earth. A very small percentage of hydrogen atoms within a human body will align with this field. When focused radio wave pulses are broadcast towards the aligned hydrogen atoms in tissues of interest, they will return a signal. The subtle differences in that signal from various body tissues enables MRI to differentiate organs, and potentially contrast benign and malignant tissue. Any imaging plane (or "slice") can be projected, stored in a computer, or printed on film.
Mammography: Mammography is an imaging technique that uses X-rays to provide a picture of the internal structure of the breast. Mammograms can be done for diagnostic or screening purposes.
Prior to 2003, film was the exclusive medium for capturing, storing and displaying radiographic images. In 2003 the Picture Archiving Communication System (PACS), a secured computer system designed for the storage, retrieval and display of diagnostic images, was implemented in the acute care facilities. PACS eliminated the need for hard film and allowed health care providers across Prince Edward Island to view images electronically.
Radiology Information System (RIS) is integrated with PACS. This electronic system allows for the storage, manipulation and distribution of patient data.
This series includes Diagnostic Imaging records which are not found elsewhere in this section.
32 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.4.2 DIAGNOSTIC IMAGING PROGRAM - CLIENTS In Diagnostic Imaging, a procedure is performed using digital imaging through one or more of the modalities listed in 3.4.1. Each time a procedure is performed it produces both an image and a report. A radiologist is a doctor who interprets or reads the diagnostic imaging film i.e., xray, mammogram, CAT scan, MRI, and ultrasound. The radiologist produces a written report on the image and this is sent to the referring physician and the referring physician then directs care to the patient.
Retention and Disposition Schedule Client Record - Images A SA FD
20 Film (Except Mammography) Hardcopy AOM+ 5y 0y D
21 Digital Images stored Electronically (PACS) AOM+ 5y 0y D
22 Mammography Breast Ultrasound - Breast MRI 5y Death + 5y D
Client Record - Report of Procedure
23 Patient Reports Hardcopy AOM+ 20y 0y D
24 Patient Reports Electronic AOM+ 20y 0y D
25 Deceased - Film, PACS, & Report AOM+ 5y 0y D
20+21- Film and Digital Images: These records are the images produced by using one of the modalities in diagnostic imaging, i.e., general radiography, bone mineral densitometry, fluoroscopy, nuclear medicine, ultrasound, CAT scans, and MRIs for clinical analysis.
22- Mammography Breast Ultrasound: The image of the breast that is produced from a mammogram for clinical analysis.
23+24- Patient Reports (Hardcopy and Electronic): The reports documenting the radiologist’s interpretation/reading of the images. Prior to 2003, this report was printed and stored in the patient file, currently the report is written and stored in the Radiology Information System (RIS).
25- Deceased - Once a patient or former patient has died their chart is flagged as deceased. This event supercedes the retention period in Sections 23 and 24.
33 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.4.3 DIAGNOSTIC IMAGING PROGRAM - RADIATION SAFETY PROGRAM Provincial Diagnostic Imaging (DI) Services provides Health PEI patients with the following diagnostic services: general x-ray, CT, mammography, nuclear medicine, MRI, ultrasound and echocardiography. The Quality Control and Radiation Safety Program is responsible for the regulatory compliance and safe use of all imaging equipment, radiation emitting devices and radioactive materials. The principle behind the program is to ensure high quality images are produced for the diagnosis and treatment of disease. A key component of the program is ensuring that radiation exposures are as low as reasonably achievable. This applies to patients, hospital staff and members of the public. The Diagnostic Imaging Quality Control and Radiation Safety Program follows all applicable regulatory requirements of the PEI Public Health Act and the associated Radiation Safety Regulations which require compliance with Health Canada Safety Codes.
Retention and Disposition Schedule A SA FD 20 Diagnostic Imaging: Equipment Testing Life of Equipment 0y Destroy
30 Diagnostic Imaging: Quality Control Checks 5y 0y Destroy
40 Diagnostic Imaging: Worker Exposure Reports Life of Facility 0y Destroy
20- Equipment Testing - This record series documents the procedures and results of functional performance/quality control testing of all equipment. This includes records such as Technologist equipment checklists, logs, forms and Medical Physicist annual reports of x-ray equipment quality control tests, and radiation safety checks.
30- Quality Control Checks (Administrative records) - This record series documents that the quality control program checks performed by staff daily, weekly, and/or monthly are being completed. The records include the date/time duties were performed and by whom. It also documents image plate cleaning checklists and the total number of images repeated or rejected by technologists on a monthly basis (this may be due to simply not having the patient positioned correctly and does not contain any patient information).
40- Worker Exposure Reports - This record series documents the amount of radiation exposure received by workers who have been assigned a Health Canada radiation dosimeter. This is a preventive monitoring tool to ensure that employees are not over exposed to radiation. All data is collected and analyzed by Health Canada. This data is kept in the National Dose Registry (NDR) and they are the holder of this information. The Radiation Safety Program is given a copy of the report of the worker’s exposure level on a yearly basis but they never receive a complete report on the life time exposure of the employee. The NDR is a database, owned and operated by Health Canada, which tracks the lifetime dose history of registered individuals.
34 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.4.4 DIAGNOSTIC IMAGING PROGRAM - NUCLEAR SAFETY PROGRAM
The Nuclear Safety Program is is a medical speciality involving the application of radioactive substances (radiopharmaceuticals) in the diagnosis and treatment of disease. A radiopharmaceutical is a drug compound or other material labeled or tagged with a radioisotope. Workers may be exposed to radionuclides in a variety of chemical forms that can be inhaled, ingested, or absorbed through intact skin or open wounds. Radiation protection programs include work area monitoring, such as surface contamination monitoring. Where intakes of radionuclides are possible, radiation protection programs should also include measurements to estimate the quantity of radioactivity deposited in the body or to establish a basis for judgment that significant intakes (in relation to applicable dose limits) of radionuclides have not occurred.
All nuclear medicine processes are licenced and regulated by the Canadian Nuclear Safety Commission (CNSC) through the Nuclear Safety and Control Act (NSCA) and associated regulations.
The Canadian Nuclear Safety Commission has the mandate to regulate the use of nuclear energy and materials, in order to protect the health, safety, and security of Canadians. The CNSC is responsible for protecting workers from exposure to radiation.
Retention and Disposition Schedule A SA FD 20 Nuclear Safety Program: Equipment Testing Greater of 0y Destroy* sealed source life or 3 years.
30 Nuclear Safety Program: Qualify Control Checks 5y 0y Destroy* 40 Nuclear Safety Program: Employee Testing Records 5y 0y Destroy* 50 Nuclear Safety Program: Shipping Documents 2y 0y Destroy*
Destroy* - all Nuclear Medicine records have an additional 90 day waiting period after sending notification to the Canadian Nuclear Safety Commission and receiving acknowledgment back from the licencing specialist. It is the responsibility of the Diagnostic Imagine Nuclear Medicine Department to ensure that this waiting period has ended and permission is granted by the Commission before sending a request for destruction to the Public Archives and Records Office.
20- Equipment Testing - These records document the procedures for leak testing of sealed sources to ensure there are no leaks of the radioactive material. A sealed radioactive source is a container of encapsulated radioactive material.
30- Quality Control Checks (Administrative Records) - These records document the procedures used to ensure standards of quality are being met when working with radioactive materials. This series of records documents the date and time of procedures and includes decommissioning and monitoring forms (documents radiation levels in rooms following administration or use of radioactive substances), wipe test records (documents radioactive contamination of rooms), and RadioPharmceutical and Isotope forms which record the drugs received and dispensed.
35 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
40- Employee Testing Records - These records document the results of thyroid bioassay and thyroid screening to monitor amount of technologist exposure to radioactive iodine. This is a preventive screening tool used to avoid the employee ever becoming at risk of overexposure. In the rare event that a worker shows overexposure, this would become an occupational health and safety issue and all documentation would be kept in the Employee file.
50- Shipping Documents- The TDG (Transportation of Dangerous Goods) form is a record of transport of nuclear substances to the Atlantic Veterinary College.
Rationale: General Nuclear and Safety Control Regulations 28. (1) Nuclear Substances and Radiation Devices Regulations 36. (2, 3 & 4) Packaging and Transport of Nuclear Substances Regulations 23. (2) Radiation Protection Regulations 10. PEI Public Health Act Cap. P 30 - Radiation Safety Regulations Health Canada Safety Code 35 (5.1)
36 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.5.1 LABORATORY SERVICES -GENERAL
Anatomic Pathology Laboratory
*This revision to the retention schedule will affect records beginning with the closed series in December, 2008, and the January 1, 2009 open series. This is about 150 reports per year, 4 cabinets of paraffin blocks, and 3 boxes of slides.* This medical discipline is comprised of three fields of study: Autopsy Pathology; Cytopathology; and Surgical Pathology.
3.5.2 AUTOPSY PATHOLOGY
Autopsy is an internal and external examination of the body after death. The purpose is to render an opinion regarding the cause and manner of death.
Microscope slides for autopsy cases usually contain many more slides per case than normally seen for surgical specimens. These larger slide cards are contained within an 8.5" by 11" envelope with the associated pathology report(s), consult(s) and photograph(s) (if taken). Since January 1, 2010, autopsy slides are filed back-to-back in chronological order in stackable cardboard filing systems (a box 4" X 12" X 12" with 4 drawers per box).
Retention and Disposition Schedule
Autopsy Pathology OPR
A SA FD -99 Consultations 2y 98y Destroy -100 Detailed Work Lists 2y 0y Destroy -105 Paraffin Blocks Adults & Children 2y 98y Destroy -115 Reports Adults & Children 2y 98y Destroy
-125 Requisitions 2y 0y Destroy -130 Slides Adults & Children (Abnormal) 2y 98y Destroy -145 Wet Tissue 8 weeks 0y Destroy after report issued
Retention was 38 years - increased to 100 years as a result of changes to the Canadian and American Association of Pathologies, and QEH Pathology cases are classified as Forensic (medicolegal) rather than hospital autopsies.
37 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.5.3. CYTOPATHOLOGY
Cytopathology is the study of cells for the detection of cancerous or otherwise abnormal cells. Cytological techniques involve the production of biologically stained microscope slide preparations of patient cells for interpretation by cytotechnologists and pathologists.
The cytologic preparation of patient specimens results in two different categories of specimen: a) Gynecological specimens are PAP smears on a glass microscope slide and sealed with a thin glass cover (coverslip). Each slide is labelled with the year, the accession number and the slide identifier(s) if applicable. b) Non-gynecological specimens are generally preparations of cells obtained from bodily fluids or fine needle aspirations of patient organs, also on a glass microscopic slide and sealed with a thin glass cover (coverslip)
The preparation process for both of these specimen types renders them no longer infectious in nature. Patient slides containing abnormal cells are retained for 20 years. These slides are filed in 4" x 6" envelopes with all relevant information pertaining to the contents clearly printed on the outside. These envelopes are stored in numerical order in shoe boxes.
Retention and Disposition Schedule Cytopathology: Records dated up to December 31, 2008 A SA FD 20 -Slides (Negative) 5 years 0 years Destroy 30 -Slides (Positive) 2 years 36 years Destroy 40 -Report 2 years 36 years Destroy
38 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.5.4 SURGICAL PATHOLOGY
Surgical pathology involves the gross and microscopic examination of surgical specimens that provides for definitive diagnosis of disease. Histology means, literally, the study of tissue. Tissues excised from the body either at the time of biopsy, surgery or autopsy are prepared by the histotechnologist for examination by a pathologist. Histolgical techniques make it possible for the pathologist to determine what, if any, disease processes are present in the patient. For instance, biopsies obtained from a lump found in the breast will be submitted to histology for evaluation and diagnosis. The hematoxylin and eosin stain (H&E stain) is probably the most widely used histological stain. A comparatively simple staining procedure it allows for the clear demonstration of a large number of tissue structures.
The histologic preparation of patient specimens results in two different types of archival specimen material: a) A block of fixed patient tissue, infiltrated with paraffin wax. “Fixed” refers to the chemical preservation of the biologic material to arrest the decomposition process. Fixation in turn renders the specimen no longer infectious in nature. Each paraffin block is labelled with the year (2 digit), an accession/case number, and a block identifier (ie A, B, C etc. and/or 1, 2, 3 etc.). Blocks are filed in numeric order in special block filing cabinets. The drawers of these cabinets are labelled with the year and the range of accession numbers contained within. The autopsy blocks are filed in separate cabinets from the surgical blocks.
B) A histochemically stained thin section of the patient specimen (cut from the wax block) mounted on a glass microscope slide and sealed with a thin glass cover (coverslip). These too are labelled with the year, the accession number, the block identifier(s) and the type of staining procedure used (if different from the routine H&E). Slides are inserted into paper sleeves to separate and organize them for ease of retrieval.
Other archived material included with the histology specimens is the pathology report(s) that go with each case. In the case of surgical type specimens, the reports are folded around the slides for the case and packed in small (4”x 6”) envelopes with all the relevant information pertaining to the contents, clearly printed on the outside. These are in turn, stored in numerical order in shoe boxes. These boxes are labelled on one end, with the year and the range of accession numbers held within.
Retention and Disposition Schedule Surgical : Records dated up to December 31, 2008 A SA FD 20 -Parafin Blocks 2 years 36 years Destroy 30 -Slides 2 years 36 years Destroy 40 -Report 2 years 36 years Destroy
39 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
Retention and Disposition Schedule Cytopathology & Surgical Phathology OPR Records dated after Jan. 1. 2009 A SA FD -99 Consultations 2y 98y Destroy -100 Detailed Work Lists 6mos 2y Destroy -105 Paraffin Blocks Adults 2y 18y Destroy -110 Paraffin Blocks Children 2y AOM+20y Destroy -115 Reports Adults 2y 18y Destroy -120 Reports Children 2y AOM+20y Destroy -125 Requisitions 2y 0y Destroy -130 Slides Adults (Abnormal) 2y 18y Destroy -135 Slides Children (Abnormal) 2y AOM+20y Destroy -140 Slides Adult & Children (Normal) 5y 0y Destroy -145 Wet Tissue 8 weeks after report issued 0y Destroy
99- Consultations - Reports from referral laboratories that perform specialized testing and/or expert interpretation/consultation in expert cases. The requisitions and consult reports for surgical specimens accessioned after January 1, 2010 are filed in chronological order in Banker’s boxes. The surgical requisition and consult reports are filed in separate boxes as the as retention for the former is 2 years while the retention on the latter is indefinite.
100- Detailed Work Lists - Lists of work ordered and completed each day for each specimen.
105-110- Paraffin Blocks - a block of fixed patient tissue, infiltrated with paraffin wax. “Fixed” refers to the chemical preservation of the biologic material to arrest the decomposition process. Fixation in turn renders the specimen no long infectious in nature. Each paraffin block is labeled with the year (2 digit), an accession/case number, and a block identifier (i,e. A, B, C etc and/or 1, 2, 3 etc ).
115-120- Reports - Reports generated by employees of Health PEI who have a professional designation in Anatomic Pathology. Since April 1, 2008, all reports are kept electronically.
125- Requisitions - a form completed for the procurement of anatomic pathology laboratory services. Information may include: patient’s name, date of birth, PHN number, lab test requested, physician name, diagnosis, and date of collection.
130-135- Slides (Abnormal)- A histochemically stained thin section of the patient specimen (cut from the wax block) mounted on a glass microscope slide and sealed with a thin glass cover (coverslip). This refers to slides with abnormal tissue.
40 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
140- Slides (Normal) - A histochemically stained thin section of the patient specimen (cut from the wax block) mounted on a glass microscope slide and sealed with a thin glass cover (coverslip). This refers to slides with normal tissue.
145- Wet Tissue -The portion of tissue that is not used in paraffin block preparation.
41 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.6.1 CLINICAL LABORATORY SERVICES - GENERAL
Clinical Laboratory is the area of the laboratory that is comprised of four sections within the department of Laboratory Medicine: Clinical Chemistry, Hematology, Microbiology and Immunology.
Clinical Chemistry Clinical Chemistry Lab is responsible for analyzing blood, urine, stool and body fluids on a STAT and Routine basis. The tests performed here are used to assess kidney function, liver function, heart disease, tumor markers, hormone levels and respiratory status, to monitor therapeutic drug levels and to investigate some drug overdoses.
Hematology Hematology Lab deals with blood, blood-forming tissues and the related cellular components. Modern-day analysis is performed primarily by automated instrumentation, with Medical Laboratory Technicians conducting the interpretation. Analysis of blood and body fluids (stat and routine basis) can identify cells associated with a wide variety of blood disorders such as leukemia , infections and anemia. Hematology also includes investigating bleeding or coagulation disorders, such as hemophilia, and monitoring test results from patients taking anticoagulants.
Microbiology Microbiology is the study of the bacteria, fungi, viruses, and parasites that invade the body. The Microbiology Lab is often divided into the following subspecialties: Bacteriology, Mycology, Serology,Virology and Parasitology. This section of the laboratory is involved in testing the effectiveness of various antibiotics when treating patients who have an infection.
Immunology Clinical immunology is the study of diseases caused by disorders of the immune system (failure, aberrant action, and malignant growth of the cellular elements of the system). The diseases caused by disorders of the immune system fall into two broad categories: immunodeficiency, in which parts of the immune system fail to provide an adequate response (examples include chronic granulomatous disease), and autoimmunity, in which the immune system attacks its own host's body (examples include systemic lupus erythematosus and rheumatoid arthritis). This section also analyzes the results of allergy testing.
Since April 1, 2008, all patient laboratory reports performed by laboratories on the Island can be found in the electronic health record (Cerner). Prior to that, patient results are stored in the Hummingbird LIS system at the QEH since 2002, and are available for retrieval. These records include results of testperformed at the QEH laboratory in the following departments (Hematology, Immunology and Chemistry).
Laboratory Services follows the minimum guidelines for records retention as set out by the American Association for Laboratory Accreditation. This applies to all retentions in this section.
This series includes Clinical Laboratory Services records which are not found elsewhere in this section.
42 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.6.2 CLINICAL LABORATORY: PATIENT RECORDS *
Records in this series contain person health information and document the receipt of a referral for service, date and time of service provided, the exact service which was provided and to whom, employee who performed the service, and patient results.
Retention and Disposition Schedule A SA FD 20 Patient Reports/Test Results 10y 0y D 21 Bone Marrow Reports 10y 0y D 22 Reportable Infectious Disease Reports 10y 0y D 23 Laboratory Requisitions 6 mths 0y D
20- Patient Reports/Test Results: These records document the results of a serological analysis of body fluids in which the fluid is removed from the patient and analyzied by employees of Health PEI who have professional designation in Laboratory Medicine. These serological tests are performed in all four sections of the Clinical Laboratory. This analysis may indicate whether or not the individual has health problems by detecting if bacteria, disease, or infection is present. A copy of the results/report is sent back to the referring physician and the original results are kept electronically in Cerner.
21- Bone Marrow Reports: A bone marrow biopsy or aspiration is a procedure to collect a small amount of bone marrow cells or tissue for testing by employees of Health PEI who have a professional designation in Laboratory Medicine. This test may indicate whether or not the individual has health problems by detecting if disease, bacteria, or infection is present. A copy of the results/reports is sent to the referring physician and the original results are kept electronically in Cerner.
22- Reportable Infectious Disease Reports: These records document the results of any testing for communicable dieseases. Reporting of cases of communicable (infectious and spreadable) is important in the planning and evaluation of disease prevention and control. The laboratory director is required to report to the chief public health office on every instance or reasonable suspicion of a notifiable infectious disease when detected in serological analysis.
23- Lab Requisition: These forms are completed by clinicians in order to request laboratory test orders. Information may include: patient name, PHN, lab test requested, date of birth, date of collection, and referral source (physician).
43 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.6.3 CLINICAL LABORATORY: SPECIMEN DIAGNOSTIC MATERIAL
This record series documents specimen and diagnostic collection, testing, and results. A specimen collection is a sample of tissue, blood, urine or body fluid from the patient which is used for analysis and diagnostic purposes. This series gives the retention period for those specimens. However, due to the short length of time or temperature in which the specimens need to be kept, the Active and Semi-Active period will be at the facility in which the sample was taken.
Retention and Disposition Schedule A SA FD 30 Blood Slides-Normal 1 mth 0y D Blood Slides - Abnormal 1y 30y D 31 Blood Slides - Kleihauer 3 mths 0y D 32 Blood Slides - Parasitological 3 mths Positive - 5y* D 33 Bone Marrow 1 mth 99y D 34 Electrophoresis and Immunofixation gels 1y 0y D 35 PCR samples 2 mths 0y D 36 Slides-Gram Stain 14days 0y D 37 MRSA/VRE 7 days y at C* D 38 Isolates 7 days years (- C) D 39 Positive-Serology 5 days years(- C) D 40 Positive-Blood Cultures 5 days 1 mth room temp D 41 CSF - Cerebral Spinal Fluid 5 days 0y D 42 Blood Samples 5 days 0y D 43 Urine Specimens 3 days 0y D 44 Stool Samples 3 days 0y D 45 Body Fluids 3 days 0y D 46 Negative Specimens - Blood 5 days 0y D 47 Negative Specimens - Swabs 7days 0y D 48 Negative Specimens - Urine 3 days 0y D 49 Negative Specimens - Stool 7days 0y D 50 Negative Specimens - Body Fluids 7 days 0y D 51 Negative Specimens - CSF Culture mth - C 0y D 52 Negative Specimens - CSF Molecular mth C 0y D
44 A= Active (In office) SA - Semi-Active (in Records Centre) SA*=Semi-Active (on Site) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy 2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
30-32 Blood Slides: Are peripheral blood smears which are created when a thin layer of blood smeared on a microscope slide and then is stained in such a way to allow the various blood cells to be examined microscopically.
The Kleihauer is a blood test used to measure the amount of hemoglobin transferred from a fetus to a mother’s bloodstream (usually performed on Rh negative mothers) to determine the required dose of Rho(D) immune globulin to inhibit formation of Rh antibodies in the mother and prevent Rh disease in future Rh positive children.
Parasitological Slide is a specimen examined for the existence of parasites.
33- Bone Marrow: the flexible tissue found in the interior of bones. The function of the bone marrow is to produce blood cells.
34- Electrophoresis/Immunofixation: a procedure used to identify the presence of abnormal proteins, to identify the absence of normal proteins, and to determine when different groups of proteins are present in unusually high or low amounts. The gels that are produced during these procedures are read and interpreted. Alterations to the usual appearance of these patterns on the gels can help in the diagnosis of disease.
35- PCR (Polymerase Chain Reaction): a procedure used to detect the presence or absence of a virus in the blood, the level of virus present, and the genotype of the virus.
36- Gram Stain: a specimen of tissue examined to determine the presence or absence of bacteria. If bacteria are present, this microscopic test divides them into gram-negative and gram-positive organisms.
37- MRSA/vre (Methicillin-resistant Staphylococcus aureus/ Vancomycin-resistant Enterococcus) : a specimen taken to detect Antibotic Resistant Organisms in patients being admitted to hospitals.
38- Isolates: a specimen of bacterial or fungal culture.
39- Serology : a specimen taken from the patient to detect antibodies when an infection is suspected.
40- Positive Blood Culture: a specimen that is examined to check for an infection in the blood.
41- Cerebrospinal fluid (CSF): a clear colorless bodily fluid produced in the choroid plexus of the brain. The CSF occupies the subarachnoid space (the space between the arachnoid mater and the pia mater) and the venticular system around and inside the brain and spinal cord.
42-52 Samples of tissue, body fluids, blood, urine, or stool used for diagnostic purposes in testing to see if bacteria, infection,or disease are present.
45 Active (In office) SA - Semi-Active (in Records Centre) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy
2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.6.4 CLINICAL LABORATORY: ADMINISTRATIVE LAB FILES The records in this series document the day to day work in a hospital laboratory and are categorized as follows: Lab Procedures; Staff Training and Competencies; and Equipment Quality Control.
Retention and Disposition Schedule Lab Procedures - this series provides documentation that all staff working in the hospital laboratories follow polices and guidelines as set out by Health PEI to ensure that the specimen/diagnostic material is properly analyzed and stored from the time of the referral for services until the specimen reaches its final disposition. This series also ensures that once a procedure is done the results and/or report is completed and forwarded to the referring source. Active Semi-Active FD 20 Annual Review of Policies and Procedures 2y 0y D 21 Discontinued Technical Procedures 10y 0y D 22 Referred Out Reports 2y 0y D 23 Manual Work Lists - Results 2y 0y D 24 Referred Out Work Lists 6 mths 0y D Staff Training and Competency: this series documents training and competency testing that staff are required to complete as per Health PEI Laboratory policies and procedures. 30 Staff Training and Orientation Records 5y 0y D 31 Staff Competency Assessment Records 5y 0y D Equipment Quality Control - These records document the procedures used to ensure standards of quality are being met when working with laboratory equipment. This series monitors the service and maintenance of all equipment used in the laboratory. 40 Analyzer Correlation and Method Validation Results 5y Life of D Instrument* 41 External (Proficiency) Quality Control Reports 5y 0y D 42 Instrument Service Reports 5y Life of D Instrument* 43 Proficiency Evaluations and Corrective action reports 5y 0y D 44 Equipment Calibration Records (e.g. Centrifuges, 2y 0y D balances, pipettes) 45 Instrument Maintenance Sheets 2y 0y D 46 Instrument Printout not interfaced 2y 0y D 47 Internal Quality Control/Calibration Records/ Reports 2y 0y D 48 Internal QC Corrective Action Reports 2y 0y D 49 Proficiency Testing Material 2y 0y D
46 Active (In office) SA - Semi-Active (in Records Centre) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy
2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
22- Referred Out Reports: a list that provides information on laboratory specimens being sent out for testing to a referral laboratory outside the Province. This list contains: patient name, PHN, lab test requested, physician name and the sample’s accession number. This report is used to monitor the patients results to ensuring that the referral was made and results returned to the provincial lab.
23- Manual Work lists: A work list that provides testing information/results related to specimens that were performed in the laboratory. These work lists are those tests that are manually verified into the electronic health record.
24- Referred Out Work Lists: A daily work sheet that collects the personal health information and referral source information used for the referred out reports.
Operational Requirements: College of Physician &Surgeons of Alberta College of American Pathologists American Association for Laboratory Accreditation Ontario Association of Medical Laboratories College of Physicians &Surgeons of Saskatchewan
47 Active (In office) SA - Semi-Active (in Records Centre) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy
2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
3.7 STERILIZATION
This series documents the various sterilization of medical equipment/devices used in health care settings. Sterilization provides the highest level of assurance that medical equipment/devices are free of viable microbes. Documentation of the sterilization process is an essential element of the quality assurance program at each facility. Documentation is critical when determining the reasons for sterilization process failures and when products need to be recalled in the healthcare facility. This series may include but not limited to: autoclaving recording charts and log sheets indicating date; load number; items sterilized; and temperature/time settings.
Ethylene Oxide (EtO) is used to sterilize surgical instrumentation that cannot tolerate high temperature. EtO possesses several physical health hazards that merit special attention. EtO is a colourless gas and it is both flammable and highly reactive. It is acutely toxic and has been classified as a human carcinogen by the International Agency for Research on Cancer. EtO can cause eye irritation and injury to the cornea and severe irritation and blistering of the skin upon prolonged exposure. Ingesting EtO can cause gastric irritation and liver injury. Acute effects from inhaling EtO vapours include respiratory irritation and lung injury, nausea, vomiting and shortness of breath. Exposure has been associated with the occurrence of cancer, reproductive effects, mutagenic changes, neurotoxicity. EtO has been shown to cause cancer in laboratory animals and has been associated with higher incidence of cancer in humans. Adverse reproductive effects and chromosome damage may also occur from EtO exposure. The department is monitored for EtO exposure using a EtO monitoring device. The retention period for monitoring records from this series of records is significantly longer due to the risks of cancer associated with occupational exposure to ethylene oxide.
Retention and Disposition Schedule A SA FD 20 Sterilization Records 1 month 7y D 30 EtO Sterilization Records. 1 year 39y D
20- Sterilization Records include:
A) Ultrasonic Unit: The Ultrasonic Unit has been demonstrated to be most effective in removing debris from instruments that are difficult to clean. These may be instruments with crevices, ratchets, or deep grooves or teeth.
B) Pasterumatic Unit: Pasteurization is a practical, accepted, and efficient method for decontamination of respiratory and anaesthesia devices. Although it may not kill bacterial spores, pasteurization kills all pathogenic vegetative bacteria, and thus can achieve a level of disinfection, in relation to infection control purposes.
C) Instrument Utensil Washer: Intended for use in cleaning and disinfection of soiled reusable surgical instruments. It’s purpose is render items free of contaminants and to allow staff to handle them for re- processing 48 Active (In office) SA - Semi-Active (in Records Centre) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy
2014-HEALTHPEI-01 Approved Oct. 2014 HEALTH PEI Section 3: Hospital Services Records Retention & Disposition Schedule
D) The Cart and Utensil Washer Disinfector: The Cart and Utensil Washer Disinfector is a high capacity mechanical washer intended for use in the efficient washing, disinfection, and drying of utensils, carts and other miscellaneous. It’s purpose is render items free of contaminants
E) Steam Sterilizers: The Steam sterilizer is designed to steam sterilize hospital and laboratory instrumentation. Temperatures range from 100 C to 135 C.
F) Air Detection Test: The functioning of the steam sterilizer is dependent upon the removal of air from within the sterilizer chamber. The air detection test evaluates the ability of the vacuum sterilizer to reduce residuals from the chamber to a level sufficient to prevent formation of pockets of air as steam is introduced into the chamber.
G) Biological Monitoring: These are “test packs” that are used to test the sterilizers ability to function properly. Steam sterilization requires a test everyday the sterilizer is used. EO sterilization requires a test for each load processed. As well, biological monitoring for sterilization loads containing implants (eg, screws, plates. Prosthesis for total joint reconstruction). Biological monitoring plays a key role in sterilization monitoring. At present, the biological monitoring is the best means to confirm the sterility of an item. Biological indicators that give a negative result in combination with acceptable mechanical readings (pressure, temperature and time), exposure control(external chemical indicators)and pack control( internal chemical indicators) provide an assurance that the sterilization process was effective.
30- Ethylene Oxide Records: This record series records all information dealing with quality assurance of EtO and all documentation regarding monitoring of exposure of employees to Ethylene Oxide.
49 Active (In office) SA - Semi-Active (in Records Centre) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy
2014-HEALTHPEI-01 Approved July 2017 Section 3: Hospital Services 3.8 Cancer Treatment
Records Retention & Disposition Schedule
SECTION 3 HOSPITAL SERVICES 3.8 CANCER TREATMENT CENTER
50 Active (In office) SA - Semi-Active (in Records Centre) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy
2014-HEALTHPEI-01 Approved July 2017 Section 3: Hospital Services 3.8 Cancer Treatment
Records Retention & Disposition Schedule
3.8.1 CANCER TREATMENT CENTRE-GENERAL The PEI Cancer Treatment Center consists of two sites. QEH provides Medical and Radiation Oncology service, clinical trials and houses the Cancer Registry. PCH, a satellite service, provides Medical Oncology service and offers clinical trials. Radiation Oncology services have been available provincially since 1960 with Medical Oncology services beginning in 1981. In 1999, the radiation treatment service was expanded to capture data in an electronic format. In 2006 there was an upgrade to the radiation oncology suite.
For patients who receive cancer treatment, the highest quality of care and safety requires access to existing health records. With treatment improvement, a large proportion of cancer survivors are approaching a normal life expectancy. However, over their lifetime they face side-effect risks related to treatment and the potential for disease recurrence. Subsequent treatment requires detailed information describing prior interventions. A lack of access to a complete history summarizing both clinical and technical details could lead to a reduced treatment benefit.
Permanent storage of all treatment details is considered ideal, in terms of supporting long-term access to retrospective data for clinical and health policy research. This retention schedule deals with information as provided by Radiation Oncologists, Medical Oncologists, Oncology nurses, and various allied health professionals as dealing primarily with continuing care over the lifetime of cancer patients,.
A SA FD 20 CTC Medical Chart AP*+2yr 23yr Destroy AP* -active period means until date of death.
-20 CTC Medical Chart: CTC medical chart contains the patient identification, final diagnosis, consents, reports of diagnostic and treatment procedures, consultation reports, surgical reports, progress notes, orders for treatment, nurse’s notes, discharge summary, signature of attending physician, and anaesthetic records. A health record may also include strips and tracings, photographs, psychological and psychiatric assessments, correspondence, allied health professional’s reports and assessments; measurements of temperature, blood pressure, pulse rate and respiration rate, fluid balance, any other notes made by any health care professional who is providing care to a patient, and any note or communication from the patient.
The CTC Medical Chart also includes a Radiation Therapy Chart: RT chart contains technical information pertaining to the radiotherapy prescription, treatment planning, dose distribution, records of treatment, imaging and follow-up over the course of treatment.
Active (In office) SA - Semi-Active (in Records Centre) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy
2014-HEALTHPEI-01 Approved July 2017 Section 3: Hospital Services 3.9 Human Health Research
Records Retention & Disposition Schedule
SECTION 3 HOSPITAL SERVICES 3.9. HUMAN HEALTH RESEARCH
Active (In office) SA - Semi-Active (in Records Centre) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy
3.9.1 PEI RESEARCH ETHICS BOARD
It is the responsibility of the PEI Research Ethics Board (REB) to safeguard the rights, safety and well being of participants in all human subject research involving the patients, staff, and resource of data of the PEI Health System. The PEI REB provides ethics review of biomedical and other areas of health research for all programs and services of the PEI Health System, and for any individual or group within or without the Province requiring or seeking local ethics review for health related research. Research involving human remains, cadavers, tissues, biological fluids, embryos or fetses shall also be reviewed by the REB. Research involving human subjects within the Health system is reviewed to ensure that it is ethically acceptable, scientifically valid and that it will conform to the ethical guidelines of the Tri-Council Policy Statement “Ethical Conduct for Research Involving Humans” (TCPS) as well as other ethical guidelines, applicable legislation and regulatory requirements.
A SA FD
-41 REB Research Documentation AP*+1y 24y D -42 Minimal Risk Proposals AP*+5y 0y D -43 Uninitiated Proposals AP*+3y 0y D -44 Clinical Trials AP*+1y 24y D AP* = means active until the date of completion or termination of the trial. *Destroy - with final approval from Sponsor (An individual, company, institution or organization which takes responsibility for the initiation, management, and/or financing of a clinical trial)
-41 REB Research Documentation REB Research Documentation are records which document a class of activities designed to develop or contribute to generalizable knowledge. Generalizable knowledge consists of theories, principles or relationships, or the accumulation of information on which they are based, that can be corroborated by accepted scientific methods of observation and inference. All clinical trials are reviewed by the full REB. The documentation for each clinical trial reviewed by the REB will retain all relevant documents (including but not limited to: protocols; amendments; consent forms; questionnaires; diaries; interview scripts; advertisements; Investigator Brochures; available safety information; investigators’ current curricula vitae; copies of all correspondence between the REB, investigators, any external reviewers, sponsors; forms and notes concerning the initial and ongoing reviews; and any other documents that are deemed necessary). Essential documents are documents which individually and collectively permit evaluation of the conduct of a study and the quality of data produced, and should be retained as per the Good Clinical Practice Guideline (REB: Section 3.4, QI: section 4.9.5 and Sponsor: section 5.5.11).
53
Active (In office) SA - Semi-Active (in Records Centre) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy
-42 Minimum Risk Propopsals Minimum risk proposals provide documentation of studies in which potential subjects can reasonably be expected to regard the probability and magnitude of possible harms implied by participation in the research to be no greater than those encountered by the subject in the relevant aspects of his or her everyday life. Proposals which are typically considered appropriate for expedited review include:
1. Studies involving “minimal risk” to participants (surveys, interviews) 2. Extentions of previously approved proposals 3. New studies which involve only minor modification to a previously approve proposal
-43 Uninitiated Proposals: Only the correspondence of uninitiated proposals will be maintained.
-44 Clinical Trials: Clinical Trials is an investigation for use in humans of a drug, device or other therapeutic intervention that involves human subjects and that is intended to discover or verify the clinical, pharmacological or pharmacodynamic effects of the drug, identify any adverse events in respect of the drug, study the absorption, distribution, metabolism and excretion of the drug, ascertain the safety or efficacy of the drug or of the intervention being studied. Documentation: All records, in any form (including, but not limited to, written, electronic, magnetic, and optical records, and scans, x-rays, and electrocardiograms) that describe or record the methods, conduct, and/or results of a trial, the factors affecting a trial, and the actions taken. ______Rationale: Good Clinical Practice Guideline (REB: Section 3.4, Q1; section 4.9.5 and Sponsor: section 5.5.11) Essential documents should be retained as per the Good Clinical Practice Guideline (REB: section 3.4, QI: -section 4.9.5 and Sponsor: section 5.5.11). Once these requirements are satisfied and the final report of the trial is issued, only the original records need to be kept for 25 years. Duplication of documents and multiple copies are not necessary.
Retention of all records created during the conduct of a clinical trial is 25 years as per the Regulations. This retention period will allow for patient follow-up throughout the subsequent stages of drug development, assessment and marketing as well as provide the ability to assess the impact on second generation. In practice, it may be easier to calculate the starting date for record retention, as the date of completion or termination of the trial. Essential documents should be kept for the entire retention period and in their original medium. These records should be kept in a secure location to maintain their integrity and confidentiality. Access to these records should be restricted to personnel who have been appropriately trained in the management of these records.
54
Active (In office) SA - Semi-Active (in Records Centre) FD=Final Disposition AP=Active Period y=year S/O=Superseded or Obsolete Fy=Fiscal Year Cy=Current year AOM=Age of Majority SR=Selective Retention (at Provincial Archives) D=Destroy