THE SCARBOROUGH HOSPITAL - DIRECTORY OF RECORDS

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1 Type of Record I. Corporate Records Leases/Deeds Agreements/Contracts Clinical Partnerships Audits (Safety, Environment/Equipment, etc. (excluding Financial Audits)) Hospital Annual Report THE SCARBOROUGH HOSPITAL - DIRECTORY OF RECORDS Fire Safety tests and inspections Engineering drawings and blueprints Waste disposal manifests, work requisitions Maintenance Records Documentation on out breaks (i.e. SARS, etc) Communication Plans & Publications Project Management Documentation Accreditation Records of Destruction Corporate Events Inventory Management Records relating to leases for properties and equipment leased for or by the Hospital. Records relating to Business/Operational agreements, contracts, memorandums of understanding with external/internal parties. Records relating to agreements, memorandums of understanding with clinical external/internal parties. Records relating to hospital processes/practices/equipment monitoring for compliance purposes. Records relating to community updates on hospital news, events and major milestones. Records relating to the testing, function and maintenance of fire alarm devices and extinguishers. Records relating to facilities, equipment and service planning. Records relating to Ministry of Environment requirements and project work completion. Records relating to equipment usage, shipping, archiving, repairs/replacements, tracking compliance of operational processes, and requisitions. Records relating to various out breaks (i.e. SARS, etc); for recordkeeping and information sharing purposes. Records relating to the awareness and education of patients, employees and communities on various Hospital projects, programs and to manage emerging issues. Records relating to the various clinical and non- clinical projects: concept, definition, planning, implementation, close out, budget, progress, training, use of resources and internal/external communications. Records relating to Required Organizational Practices (ROPs), accreditation survey recommendations, roadmaps, action plans, consent, accountability and compliance with accreditation processes and standards. Records relating to the destruction of patient care material after meeting all recordkeeping criteria for retention. Records relating to announcements, invitations, Orders of Service, letters, program details and images for various Hospital, departmental and community based events. Records used to manage and maintain all aspects of Hospital supplies inventory for offsite facilities, clinical units, print shop and other administrative areas. The Scarborough Hospital Directory of Records December 2,

2 Corporate Documents: Documents of Incorporation Register of Directors Register of Members Hospital Policies, Procedures and Manuals Research Administrative By- Laws Executive Correspondence General Corporate Correspondence Insurance Policies Print shop forms Decisions support reports & requests Scorecards Data Reports submitted to/from internal/external parties Position Papers, Briefs, Key speeches or presentations and Media Releases Minutes: Board of Directors & Executive Meetings Committees Standing Board Committees Records relating to licences and patents The Scarborough Hospital have in their possession.. Records relating to the names and contact information of the Board of Directors. Records relating to the Annual Membership, includes contact information and names of members or potential members. Records relating to various corporate/departmental/clinical policies, procedures, protocols and manuals. Records relating to correspondences, consent, protocols, communications and data reports of various research projects conducted by or through The Scarborough Hospital. Records relating to corporate governance; setting out the form, manner or procedure in which the hospital should run. Records relating to communications with external/internal parties regarding goals, objectives, strategic priorities and departmental operations of the hospital. Records relating to the communication between external/internal parties regarding strategic clinical and non- clinical planning, directives and updates to hospital programs and operations. Records relating to the liability and property insurances of the hospital. Records relating to active forms currently being used by various hospital departments along with revision history, files of artwork/images and print job requests. Records relating to reports provided to Patient Service Groups (PSG) and Corporate Administration to support decision making processes. Records relating to the monitoring/assessment of clinical and non- clinical activities/performance based on both externally mandated and internal targets. Records relating to external/internal reports on hospital accountability, programming, statistical/legal/business reporting, performance evaluations, etc. Records relating to community outreach and partnership building, research projects, service awareness, Hospital events, strategic/clinical planning and issues facing TSH, the Board and the community. Records relating to discussions at Executive, Board, Supervisor and other senior leadership forums. Records relating to the purpose, discussions and action plans addressed in various clinical and non- clinical committees. Records relating to the discussions, agendas, membership lists and terms of reference for various standing board committees. The Scarborough Hospital Directory of Records December 2,

3 Member s Meetings Senior Leadership Forum Departmental Meeting Medical Advisory Committee: Meeting Minutes II. Financial Records General: Annual Financial Statements Financial Audits Special Contracts or Agreements necessary to understanding general ledger entries General Journal General Ledger Source Documents (i.e. records integral to the creation of financial statements and tax returns) Cancelled Cheques/Bank Statements Cheque Register Accounts Payable Transactions Expense Accounts Grant Accounts Payroll: Payroll Register T4/T4A Reports Deduction Register Records relating to agenda, minutes, information shared at the Annual General Meetings. Records relating to the discussions at various Hospital senior leadership forums. Records relating to discussions, operational updates, emerging issues and changes to policies/procedures/manuals within various clinical and non- clinical areas. Records relating to updates to the Medical Advisory Committee on hospital issues, events, changes to policies, etc. Records relating to financial performance of the hospital for management decision making purposes, annual audits and to ensure transparency. Records relating to the financial analysis and audits of hospital expenditures to ensure accountability. Records relating to legal documents that support patient billing, payment plans, collections, and the creation of the General Ledger, etc. Records relating to transactions not electronically generated by the system and the balancing of accounts. Records relating to the creation of financial statements. Records relating to the creation of tax returns to support the creation of financial statements. Records that verify accuracy and authenticity of cleared cheques in case of dispute from payees and that support the creation of financial statements. Records relating to the monitoring of cheques issued/outstanding and acting as proof of payment for authorized claims. Records relating to invoices; sessional, stipends and medical fees rendered to the hospital and/or the hospital s Foundation. Records relating to the monitoring, fiscal reporting and evaluating of spending in clinical and non- clinical areas. Records relating to the grants received and deferred to ensure they have been allocated and used for the purpose intended. Records relating to payroll and salary expenses of various departments. Records relating to wages of the preceding year and reports of withholdings required by Revenue Canada (i.e. tax, CPP, EI, etc) Records relating to withholdings taken from employees and employers. The Scarborough Hospital Directory of Records December 2,

4 Patient Accounts: Cash Receipts Customer Invoices Other Billing Invoices Bank Reconciliation Statements Bank Deposit Slips/Books Patient Valuables Envelopes/Security Register Revenue Journals: Reports and Worksheets Miscellaneous Accounting Records: Budget and Budget Analysis Records supporting GST rebate or refund Employee Health Tax Returns OHIP Records WSIB Reports Other financial records relating to patient care Other Tax Returns Procurement Records: Procurement justification and/or Business Case RFX s (process of supplier selection for products or services) Vendor Submissions Vendor Selection Documentation (i.e. Confidentiality Agreements, evaluation, scoring, etc) Records relating to sales transactions and the daily reconciliation of cash. Records relating to patient and non- patient billing. Records relating to invoices to external parties for the use of hospital property and resources. Records relating to the inflow/outflow of cash and to verify the accuracy of cleared cheques and deposits. Records relating to cash reconciliation and collection by the Hospital and the Hospital Foundation. Records relating to the safe keeping of patient valuables. Records relating to the collection, reconciliation and analysis of funds by various clinical and non- clinical areas. Records relating to the analysis of financial operating variances in clinical and non- clinical areas for management decision making purposes. Records relating to the GST and HST refund for the hospital and/or hospital s Foundation. Records relating to the summary of insurable payroll during a calendar year and monthly remittance to help prepare annual Employee Health Tax returns. Records relating to OHIP billing, physician registration, remittance and reconciliations. Records relating to documentation to/from WSIB regarding claims management and status of claims. Records relating to the finance and expense of various clinical programs and Provincial Healthcare Initiatives (i.e. Ontario Care Costing Initiative (OCCI), etc). Records relating to tax returns from the Canada Revenue Agency (excluding Employee Health Tax Returns). Records relating to capital budget submissions, proposals from vendors, contracts, proposed initiatives and market research for clinical and non- clinical development. Records relating to the development of the RFP (i.e. vendor proposals, RFP templates, samples of RFPs and RFIs, etc). Records relating to RFP/RFQ/RFI submissions and tendering packages from various vendors. Records relating to the competitive process of selecting vendors. The Scarborough Hospital Directory of Records December 2,

5 Correspondence/Vendor Communications Purchase Order/Requisitions III. Payroll/Human Resources Records Employee Records: Canada Pension Plan Contributions Designated Substance Exposure Records Employee Records Labour Relations Records (Grievances, Mediation, Arbitration) General Employment Records Employee Information Recruitment (i.e. hiring/interview notes, reference checks, letters, advertising, job fairs/postings) Miscellaneous Employment records and documents Training Records/Materials Duty Assignments Physician Appointment Records HOOPP Records Individual Contributions Workplace Accident/Incident Investigation Records Occupational Health and Safety Records Compensation and Benefits Records Records relating to vendor correspondences about product/service purchased or being considered by the hospital. Records relating to departmental and Patient Service Group (PSG) purchases of supplies and quotes from various vendors. Records relating to CPP contribution reports (employee and employer portions) Records relating to the assessment/investigation of designated substance exposures involving staff used as a quick reference for the Ministry of Labour (MOL) and exposure follow ups. Records relating to the employment history of active/inactive employees (i.e. salary, PDRPs, sick/vacation time, performance management, investigations/follow- ups, personal/medical leaves, contracts, letters, etc.) Records relating to the bargaining process, collective agreements, grievances, mediation, arbitration and awards. Records relating to employee workload, attendance management programs and employee opinion survey results, etc. Records relating to contact information of Hospital s staff, Chaplains, Churches, and volunteers information, etc. Records relating to the recruitment cycle for both union and non- union vacancies. Records relating to managerial notes on current employees, community member applications, probation and transfer trial reviews, etc. Records relating to the education of staff/volunteers on clinical and non- clinical policies/processes (i.e. training materials such as presentations, handouts, attendance sheets, etc). Records relating to the scheduling of staff, for tracking and payroll purposes. Records relating to applications and re- appointment forms for physicians along with any supporting documentations. Records relating to employee contribution to the Healthcare of Ontario Pension Plan. Records relating to accidents/incidents in the workplace which may contain aggregate staff information. Records relating to WSIB claims costs, inspections, public health notices, safety concerns, MOL orders, exposure reports, safety training, and medical documentation to support sick leaves and return to work programs. Records relating to salary, benefits, EAP Programs, severance/exit payouts, maternity, retirement, short/long term leave and pensions. The Scarborough Hospital Directory of Records December 2,

6 Payroll Deduction Authorization Records relating to the staff authorization of payroll to make Forms deductions to their salary for a specific payroll withholding. Payroll Journal Sheets Records relating to payroll transactions not electronically generated by the payroll system. Time Cards/Sheets Records relating to tracking work time, attendance, monthly rotations, etc. Union Dues Deduction Sheets Records relating to union dues deducted from unionized employee s earnings. Material Safety Data Sheet (MSDS) Records relating to products being used by various departments in the hospital including the properties, handling instructions, hazards, etc associated. Credentials/Medical Staff Files Records relating to contact information, certification, reapplication, evaluation and clinical practice activity of medical students, preceptors and physicians. IV. Quality and Risk Management Records Patient/Visitor Incident Reports Records relating to patient/visitor incidents, follow ups, and occurrences. Patient Concerns Records relating to complaints, investigations, family concerns, positive feedback, follow ups, and notes regarding patient care and other hospital services. Patient Satisfaction Survey Results Litigation Files Disaster Plans Medical Alerts/Recalls Security Database Surveillance Risk Management Reviews/Investigations Risk Management Consultations Records relating to tracking, measuring and reporting patient satisfaction. Records relating to legal cases (open/closed), correspondences and statistics for the hospital. Records relating to plans for provision of care to patients, procedures for patient transport and emergency contact lists. Records relating to risk associated with medical equipment communicated by vendors and shared with staff/physicians. Records relating to ID badges, video surveillance, door location in buildings, staff access and door key issuance. Records relating to responses/amendments to privacy breaches and recommendations to address identified processes and clinical issues. Records relating to risk assessments and opinions. V. Patient Care Records and Other Materials Pharmacy Records: Controlled Drug Records - Inpatient Records relating to regulatory requirement for tracking of all and Outpatient Radiopharmaceutical inventory Narcotic records, Controlled Drug Records relating to Pharmacists Registration with the Ontario College Records and Out- Patient of Pharmacist for authorization to sign for narcotics and controlled prescriptions drugs. The Scarborough Hospital Directory of Records December 2,

7 Inpatient and Outpatient Prescriptions and supporting documentation Records of Dispensing Drug Equipment Alerts and Recalls Nursing Unit Records: Assignment Sheets Work Schedules Miscellaneous: Patient Call Back Records (Spiritual & Religious Care) Patient Care Logs/Notices/Profiles/Reports Patient Profile Inpatient Records relating to requests submitted to Health Canada for Special Access, investigational and emergency release drugs and reimbursement for patients on various drugs. Records relating to vendor submissions to access drugs for medical treatments and compassionate drugs received and dispensed to patients. Records relating to tracking drug items recalled by manufacturers. Records relating to the assignment of nurses, practitioners and other medical staff in various Patient Services Groups (PSG). Records relating to the scheduling of clinical staff in various Patient Service Groups (PSG). Records relating to referrals to follow up and statistic in Spiritual and Religious Care. Records relating to admission logs, notices, patient profiles and reports generated in various Patient Service Groups (PSG). Records relating to recordkeeping, intervention and follow ups of patient care matters. The Scarborough Hospital Directory of Records December 2,