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Retention and Security of UW OTD Patient Records and Hospital Development Records (1.06)

Retention and Security of UW OTD Patient Records and Hospital Development Records (1.06) - Policies, Administrative, UWHC, Department Specific, UW Organ and Tissue Donation

1.06



POLICY
Established Date: September 2005
Effective Date: January 2018
Title: Retention and Security of UW OTD Patient
Records and Hospital Development
Records
Policy Number: 1.06

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 1 of 3

PURPOSE

The purpose of this policy is to establish guidelines for the retention of UW OTD patient records related to
organ donor referrals, organ offers, local organ donors, and imported organs and to describe patient record
security measures. It is the policy of the University of Wisconsin Organ and Tissue Donation (UW OTD) to
securely retain patient records as required per all applicable regulations and state law. In addition, this
policy establishes a system for maintaining UW OTD hospital development (HD) records from HD binders
and chart reviews.

POLICY

Patient Records Created Prior to 01 January 2011
A. Patient records from organ donor referrals, local organ donors, and imported organs will be
archived at the Wisconsin State Records Center storage facility for a minimum of 10 years in
accordance with applicable regulations and state law and University of Wisconsin Hospital and
Clinics (UWHC) policy 6.26.
B. Organ offer records will be maintained in the UW OTD Donor Tracking Database maintained
electronically by UW OTD and UWHC Information Technology Services.
C. Chart security will be maintained through the following:
1. Use of proximity access cards and locks at the UW OTD office.
2. Secure storage at the state storage facility.
3. Secure access to electronic records as mediated by UWHC Information Technology
Services.
4. Use of secure servers and data backup systems maintained by UWHC Information
Technology Services policy.

Patient Records Created On or After 01 January 2011
D. All patient records will be maintained electronically in the UW OTD electronic donor medical
record by UW OTD and UWHC Information Technology Services.
E. Electronic donor medical records will be maintained for a minimum of 10 years in accordance
with applicable regulations and state law and UWHC policy 6.26.
F. Chart security in electronic donor medical record: the electronic donor medical record will be
maintained through the following:



POLICY
Established Date: September 2005
Effective Date: January 2018
Title: Retention and Security of UW OTD Patient
Records and Hospital Development
Records
Policy Number: 1.06

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 2 of 3
1. Secure user name and password access.
2. Security roles established for each user to limit data viewing and editing capabilities.
3. Use of secure servers and data backup systems maintained by UWHC Information
Technology Services policy.
4. An audit trail feature to capture information about data entry and editing.

Electronic Donor Medical Record Security Roles
G. The security roles for new employees will be determined by the hiring manager.
H. Access to the electronic donor medical record will be terminated on the last date of
employment.
I. Changes to security roles will be completed according to the following process:
1. Any change to security roles will be determined by the hiring manager.
2. The hiring manager will discuss the change with the employee prior to implementation.
3. The hiring manager will notify the electronic donor medical record Information Services
team.
J. Security roles for all users will be periodically reviewed and updated as needed.

HD Binders
K. UW OTD will organize HD binders and chart review records annually after year-end statistics
have been filed for each hospital in the UW OTD donation service area.
L. HD binder records for hospitals will be maintained onsite at the UW OTD office as follows:
1. Hospital Profile
i. Maintain current year.
ii. Discard earlier versions.
2. Letter of Agreement
i. Maintain current version.
ii. Send earlier versions to the state storage facility.
3. Clinical Laboratory Improvement Amendment (CLIA)
i. Maintain current certificate.
ii. Discard outdated versions.
4. Hospital Development Plan and Yearly Assessment
i. Maintain most recent four years.
ii. Send earlier versions to the state storage facility.
5. Policies and Procedures



POLICY
Established Date: September 2005
Effective Date: January 2018
Title: Retention and Security of UW OTD Patient
Records and Hospital Development
Records
Policy Number: 1.06

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 3 of 3
i. Maintain most current versions.
ii. Discard earlier versions.
6. Death Reporting Compliance (Quarterly Fax Confirmation Sheet Tab in binder)
i. Maintain most recent four years.
ii. Send earlier versions to the state storage facility.
7. Statline Reports
i. Maintain current year.
ii. Send earlier versions to the state storage facility.
8. Hospital Specific End-of-Year Statistics
i. Maintain most recent four years.
ii. Send earlier versions to the state storage facility.

Chart Review Records
M. Chart review records will be stored by hospital and year in a file cabinet at the UW OTD office.
N. The schedule for maintaining records onsite is as follows:
1. Maintain records from current and prior calendar year.
2. Send earlier records to the state storage facility.

REFERENCES

UWHC Policy 6.26