/policies/,/policies/administrative/,/policies/administrative/uwmf/,/policies/administrative/uwmf/uwmf-wide/,/policies/administrative/uwmf/uwmf-wide/record-retention/,

/policies/administrative/uwmf/uwmf-wide/record-retention/116001.policy

201410297

page

100

UWMF,

Policies,Administrative,UWMF,UWMF-wide,Record Retention

Record Retention (116.001)

Record Retention (116.001) - Policies, Administrative, UWMF, UWMF-wide, Record Retention

116.001







Page 1 of 23

Name: Record Retention Policy Number:
__X__ New ____ Revised Effective Date: June 1, 2009
Approved By: University of Wisconsin Medical
Foundation Senior Management Committee
Date: June 1, 2009

Peter H. Christman
Title: Executive Vice President
Reviewed



I. PURPOSE

This University of Wisconsin Medical Foundation, Inc. (“UWMF”) policy provides uniform guidance for the
retention of various records, in order to ensure appropriate retention of UWMF’s records for internal
business purposes, to meet legal requirements, and to promote the cost-effective management of
records.

II. POLICY

It is the policy of UWMF to store and retain records in accordance with this Record Retention Policy,
which encompasses the following criteria:

1. It is UWMF’s policy to maintain complete, accurate and high quality records. Records
are to be retained for the period of their immediate use, unless longer retention is
required for historical reference, contractual or legal requirements, or for other purposes
as set forth herein.

2. Records that are no longer required, and have satisfied their required periods of
retention, are to be destroyed uniformly in a manner that ensures the confidentiality of
the records.1 Appropriate management staff shall approve the destruction of records. It
is recommended that such approval be made in writing.

3. The unauthorized destruction, removal or use of records is prohibited.

4. All employees and contractors are responsible for ensuring that accurate and complete
records are identified, retained, stored, protected and subsequently destroyed within
their area of assigned responsibility.

5. All records generated and received by UWMF are the property of UWMF. No UWMF
employee or contractor, by virtue of his or her position, has any personal or property
right to such records even though he or she may have developed or compiled them.

1
See UWMF policy, entitled “Destruction/Disposal of Patient Protected Health Information Media” for guidance on acceptable
destruction methods.







Page 2 of 23

6. Paper records may be scanned to ease storage demands; however, as with paper
records, care must be taken in the storage of electronic records to ensure the quality of
the record for at least as long as the minimum recommended retention time.

III. REFERENCES

 Destruction/Disposal of Patient Protected Health Information Media
 E-Discovery Policy
VI. Author & Review

Sponsor: Legal Services Department
Authors: Claudia Jane Sanders Amanda K. Reese
Ericka Watson Elizabeth A. Marshall
Review: UWMF E-Discovery Work Group Michael Best & Friedrich
UWMF Senior Management




Approved: ___________________________________________
Peter H. Christman

Date: June 1, 2009







Page 3 of 23

TYPE DESCRIPTION RETENTION
PERIOD
CITATION
ACCOUNTING / FINANCIAL DEPARTMENT
General Audited financial reports (See
Admin/Financial Reports)
Permanent
Bank deposit slips 7 years * 26 CFR
301.6501(e)-1
Bank statements 7 years *
Bank reconciliations 7 years *
Billing invoices/statements for
groups and individual health
10 years *
Budget (See Admin/Finance) 6 years
CPA work papers and
communications
7 years after date
of audit report

Cancelled checks 7 years Wis. Stat 893.432
Cash receipts 7 years *
Chart of accounts 7 years
Depreciation records Permanent *
Expense reports/records 7 years *
General ledger Permanent *
Journals Permanent *
Regulatory financial
statements
3 years
Supporting schedules 7 years
Profit and loss statements Permanent
Check registers 7 years
Payroll






Absentee reports 3 years Wis. Admin. Code §
DWD 272.11 (1998)
Earning records Permanent ERISA 29 USC
1027
Garnishments 7 years
Payroll checks 7 years Wis. Admin. Code §
DWD 272.11 (2005)
Social security reports 4 years 26 CFR 31.6001-1

2
All references to the Wisconsin Statutes are to the 2005 -2006 version unless otherwise noted.







Page 4 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION








Tax reports
Unemployment tax
records
Withholding tax-state W-2
Withholding tax exempt
W-4
7 years 26 CFR 31.6001-1
Timesheets 7 years Wis. Admin. Code §
DWD 272.11 (2005)
Payroll Deductions 7 years
Bonuses 7 years
Taxes Tax returns (See
Admin/Corp)
Permanent
Tax appeals Permanent
ADMINISTRATIVE
Acquisitions Closing documents- Permanent Wis. Stat. 181.1601
Due diligence (work papers) 7 years
Committee
Records
Corporate committees (See
Corp. Records)
Permanent Wis. Stat. 181.1601
Contracts/Leases Contracts Contract term
plus 6 years
Wis. Stat. 893.43
Leases Contract terms
plus 20 years

Corporate
Records
Articles of Incorporation Permanent Wis. Stat. 181.1601
Ballots from Board elections Permanent Wis. Stat.
181.1601(3)
Ballots from Committee
elections
Permanent Wis. Stat.
181.1601(3)
Board minutes Permanent Wis. Stat.
181.1601(1)
Bylaws Permanent WI Stat. 181.1601
Consultant reports 3 years
Record of actions taken by
shareholders or Board of
Directors without a meeting

Permanent Wis. Stat.
181.1601(b)
Secretary of State annual Permanent WI Stat. 181.1601







Page 5 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
report
Financial Reports




Audited financial reports Permanent
Benefit tax returns Permanent
Budget 6 years
Tax returns Permanent
Tax appeals Permanent
Insurance Policies Liability and property,
including malpractice
Permanent
Legal/Risk Files
Operations Policy and procedures Permanent
Real Estate Appraisals Permanent
Closing property documents Permanent
Construction documents Permanent
Deeds Permanent
Property easements Permanent
Civil Litigation &
Claim Issues
Litigation Files 15 years after
close, or, if matter
involves a minor,
3 years after
minor reaches
age of majority
(18), whichever is
later.


Incident & accident reports 3 years from the
date of incident if
no claim filed, or,
if matter involves
a minor, 3 years
after minor
reaches age of
majority (18),
whichever is
later. If claim is
involved, same
as for Litigation
files above.










Page 6 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
General General inquiries,
miscellaneous guidance, etc.
15 years after
close, or, if matter
involves a minor,
3 years after
minor reaches
age of majority
(18), whichever is
later.

BUILDING SERVICES
Blueprints Blueprints & building
schematics
Permanent
Cleaning Records Facility Cleaning Records
(not contracts)
3 years
Equipment
Records
Equipment inspection records Life of equipment
plus 7 years

Maintenance log 10 years or life of
equipment plus 3
years, whichever
is earlier

Operating instructions Life of equipment
plus 7 years

Warranties Life of warranty
plus 7 years

Inspection
Records
Grounds and buildings 7 years
Fire extinguisher records 6 years
Purchase Orders Capital equipment 10 years
Other 4 years
BUSINESS OPERATIONS – PATIENT BUSINESS OFFICE
Assignment of
Benefits
An arrangement by which a
patient requests that their
health benefit payments be
made directly to a designated
person or facility, such as a
physician or hospital.
7 years
Claims Health Insurance Claim
Forms, paper and electronic
transmitted to payers
requesting payment for
patient health services

7 years







Page 7 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
EOBs/EOPs Explanation of
Benefits/Payment from the
health insurance carriers
7 years
Encounter Forms Document used to report UW
Health providers’ service to
patient for manual charge
entry into HealthLink
7 years
ECT Confirmation
Reports
Confirmation from payer that it
has received our claims and
generally part of the
claim/payment exchange
process.
7 years
Microfiche Archived patient data and
monthly batch summary
reports
7 years
Patient/Insurance
Correspondence
Incoming mail regarding a
patient account.
7 years
CARE AND QUALITY INNOVATIONS
Data Request
Process Database
e-forms / generates a project
plan document
Ongoing
Project
Management
Database /
Process
Improvement
Ongoing
Performance
Improvement
Project

Clinical improvement
documentation includes
minutes, agendas, charters
7 years
Performance
Improvement Data
Analysis
7 years
Research Related
Requests / HIP
7 years
Insurance Data
Feeds (PPIC &
UHP)

Payment, treatment, health
care operations
1 year
Ambulatory Care
Innovation Grant

Applications and awards 7 years







Page 8 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
CARE MANAGEMENT
Care Management Case management files
(Refer to UHP requirements)
Retain as long as
the related
insurance
remains in force
plus a minimum
of 3 years

Referrals (Refer to UHP requirements) Retain as long as
the related
insurance
remains in force
plus a minimum
of 3 years (for
OCI audit
purposes)

COMPLIANCE
Correspondence
(letters, memos,
e-mail)
Written to governmental
agencies including OIG,
CMS, DHFS, Medicare,
Medicaid including attached
medical record
documentation
Permanent Wis. Admin. Code
HFS 106.02(9)(d)3
Compliance
Meeting Minutes
Compliance and Audit
committees’ minutes
10 years
Training/
Education
Records of Education
Sessions
10 years
Rosters of Attendees 10 years
Handouts 10 years
Hotline Call Log 10 years
Compliance-
Projects
Permanent
Routine Internal
Review
Review Worksheets 10 years
Review Results Database 10 years
Medical Record
Documentation
10 years
CLINIC PATIENT RECORDS / HIM
Birth and Death Permanent

3
Although Wis. Admin. Code HFS 106.02(9)(d) requires only 5 years, UWMF has chosen to permanently retain this
information







Page 9 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
Records
Medical Record 25 years
Acknowledgment
of Receipt of
Notice of Privacy
Practices
NPP Acknowledgment 6 years after it
was last in effect
45 CFR
164.530(j)(2)
Accounting of
Disclosure Forms
Accounting of disclosure
forms
6 years from the
date of disclosure
45 CFR
164.528(a)(3)
GOVERNMENT PROGRAMS
Medicaid and
Medicare
Programs
All reports filed for the
Medicaid and Medicare
programs
10 years
HUMAN RESOURCES
Advertisements
for Employment
Employment ads: radio,
newspaper, online
1 year 29 CFR 1627.3
(b)(1)(vi)
Applications Non-employee 1 year 29 CFR 1627.3
(b)(1)(i)
Employee Term of
employment plus
3 years

Benefit Records Benefit plan document and
related information (non-
retirement)
At least one year
after termination
of plan
29 CFR
1627.3(b)(2)
COBRA notices 6 years
FMLA documentation 3 years from
termination of
employment
29 CFR 825.500(b)
Retirement / pension / 401 K
plan document and
beneficiary forms
Permanent
Tax record Permanent 29 USC 6501
Reports and supplemental
information
6 years after filing 29 USC 1027
Americans with Disabilities
Act (ADA) Documentation
1 Year from
making record or
taking the
personnel action

Human Resources
Compliance
Affirmative Action Plan

2 years after last
in effect
41 CFR 60-250.41







Page 10 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION








Employment Verification
Form I-9 under Immigration
Reform and Control Act of
1986
The later of three
years following
date of hire or
one year
following date of
termination of
employment
8 CFR 274a.2
Equal Employment
Opportunity
Copy of the most
recent
29 CFR 1602.7
Equal Pay Act 2 years 29 CFR 516.6
Vietnam Vets and
Handicapped
Permanent 41 CFR 60-250.41
Employee manuals While current
plus 3 years

Job
Classifications
Permanent
Job Descriptions 7 years

Personnel Files
All records in employee files,
including employee
evaluations and termination
records

Term of
employment plus
6 years

WI Stat. 893.43
Wage and Salary
Admin. Manual
6 years WI Stat. 893.434
and 29 CFR 516.6
Workers Comp Claims (UWMF employee) 12 years from
date of
injury/death or
last payment of
compensation,
whichever is the
latest
29 CFR 1904.33
Test Results from Physicals For employees
employed for at
least 1 year, term of
employment + 30
years.
For employees
employed for less
than 1 year, 12
years.


4
UWMF follows the Wis. Stat. guidelines over the 2 years required by the CFR







Page 11 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
Log of Occupational Injuries and
Illnesses
5 years
Hazardous Materials
Exposure Records
Term of
employment plus
30 years

INFORMATION SYSTEMS
Archiving Source Documents for
Electronic Records
90 Days after
entered in
system

E-mail Subject to
separate policy

Licenses Term of License
plus 6 years

Personal Hard
Drive Files
Subject to e-
Discovery Policy

Security Audits Maintained until Issues are
remediated
UWHCA Heat
Ticket System –
subject to
separate policy

Tape Storage Daily Back-up Tapes 7 days
End of Month back-up Tapes 1 year
End of Year back-up Tapes 7 years
MARKETING
Advertisements Clippings Indefinite
Newspaper 5 years
Radio 5 years
Television 5 years
Press Releases Indefinite
Publications In-house 7 years
Requests for
Proposals
RFPs 7 years following
termination of
contract

LAB AND RADIATION
Proficiency
Testing Program
Performance
Reports
5 years or such
time as may be
needed for any
legal proceedings
42 C.F.R. § 493.903







Page 12 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
Laboratory
Equipment Test
Records
Records of test requisitions
and test authorizations,
including the patient’s chart
or medical record if used as
the test requisition or
authorization
2 years 42 C.F.R. §
493.1105(a)(1)
Laboratory
Equipment
Testing Procedure
A copy of each test
procedure including the date
of initial use and
discontinuation must be
retained
2 years after the
test procedure is
discontinued
42 C.F.R. §
493.1105(a)(2)
Laboratory test
requisitions and
authorizations for
slides, blocks and
tissue
2 years 42 C.F.R. §
493.1105(a)(1)
Laboratory test
procedures for
slides, blocks and
tissue
2 years after a
procedure has
been
discontinued
42 C.F.R. §
493.1105(a)(2)
Analytic systems
records, including
laboratory quality
control and
patient test
records for slides,
blocks and tissue
Must include all quality
assessment records
indicating monitoring
assessment and resolution of
problems and revisions of
policies necessary to prevent
recurrence. Patient test
records should include
instrument printouts if
applicable
2 years 42 C.F.R. §
493.1105(a)(3); See
also 42 C.F.R. §
493.1283-.1289
Proficiency
Testing Records
for slides, blocks
and tissue
2 years 42 C.F.R. §
493.1105(a)(4)
Laboratory quality
system
assessment
records for slide,
blocks and tissue
2 years 42 C.F.R. §
493.1105(a)(5)
Laboratory Test
Reports
Including final, preliminary
and corrected reports
2 years after the
date or reporting
42 C.F.R. §
493.1105(a)(6)
Pathology Test
Reports
10 years 42 C.F.R. §
493.1105(a)(6)(ii)







Page 13 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
Cytology slide
preparations
5 years from the
date of
examination
42 C.F.R. §
493.1105(a)(7)(i)(A)
Histopathology
Slides
10 years from
date of
examination
42 C.F.R. §
493.1105(a)(7)(i)(B)
Pathology
Specimen Blocks
2 years from the
date of
examination
42 C.F.R. §
493.1105(a)(7)(ii)
Remnants of
tissue for
pathology
examination
Until a diagnosis
is made on the
specimen
42 C.F.R. §
493.1105(a)(7)(iii)
Immuno-
hematology
records, blood
and blood product
records and
transfusion
records
Include records concerning
the donor, processing, quality
control, transfusion reactions
and complaints and general
records such as dates of
various entries, expiration
dates and identification of
person performing the work.
An interval
beyond the
expiration date of
the blood or
blood component
as necessary for
the reporting of
any unfavorable
conditions, but no
less than the
later of 5 years
after completion
of records of
processing or 6
months after the
expiration date.
If there is no
expiration date,
the record should
be retained
indefinitely.
42 C.F.R. §
493.1105(a)(3)(ii);
21 C.F.R. §§
606.160
Original
authenticated lab
reports
To be filed with
original medical
record
Wis. Admin. Code §
HFS 124.17(1)(f)
Duplicate
authenticated lab
report
2 yrs Wis. Admin. Code §
HFS 124.17(1)(f)
Radiological
reports
To be filed with
original medical
record.
Wis. Admin. Code §
HFS 124.18(1)(e)1







Page 14 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
General Images –
Portable Xrays,
copies of
radiological
reports, printouts,
films, scans and
other image
records
Adult Patients (18+)
Except for Asbestos
Exposure, Chest Exams,
Mammography and
Employee Work Related
Injuries.
7 years Wis. Admin. Code §
HFS 124.18(1)(e)4;
42 CFR
482.26(d)(2)
Minor Patients (>18)
Except for Asbestos
Exposure, Chest Exams,
Mammography and
Employee Work Related
Injuries.
Until patient is 25
years of age.

Patients Exposed to
Asbestos
7 years following
date of death

Deceased adult patients -
For images on file at time of
death.
7 Years following
date of death

Deceased minor patients –
For images on file at time of
death
Maintained until
the date patient
would have
turned 25 years
of age

Chest Exams – Most Recent
PA and Lateral chest exams
Permanent
Mammography 10 years, except
that the three
most recent
exams must be
retained for 7
years following
date of death

Films In Litigation –
Films related to patients or
matters in controversy where
we are on notice that litigation
has or will ensue.

For as long as
noted above, or
until notification
that the case is
closed, or for 12
years from the
date of exam,
whichever occurs
later.








Page 15 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
WC Claims - UWMF
employees who are patients
and who have made WC
claims
30 years
Nuclear Medicine
Reports
Signed and dated reports of
nuclear medicine
interpretations, consultations,
and procedures
To be filed with
original medical
record copies to
be retained by
service.
Wis. Admin. Code
§ HFS 124.18(4)(f)1
(no duration
specified)
Inspections of x-
ray machines
6 years 42 CFR § 48610(b)
Tissue usage Records: Track and identify
materials used to prepare
and process tissues and
instructions used for
preparation; identify staff
involved in preparing or
issuing tissue; identify staff
who accept tissue; include
dates and times of activities;
include documentation in
recipient's record of tissue
use; include documentation
of unique identifier of tissue;
include storage temperature;
include superseded
procedures, manuals and
publications; include source
facility; include donor and lot
identification; include final
disposition of tissue; and
include expiration date
10 years beyond
the date of
distribution,
transplantation,
disposition or
expiration of
tissue

JCAHO manual
PC.17.20

Records of
Human Tissue
Intended for
Transplantation
Records of suitability of the
donor including infectious
disease screening, may be
electronic, paper or true copy
(such as microfiche or
microfilm)
10 years beyond
the date of
transplantation,
distribution,
disposition or
expiration
whichever is
latest
21 C.F.R. §
1270.33(h)







Page 16 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
Records relating
to organ donation
and
transplantation
Human readable or
reproducible paper or
electronic format; The record
must include donor
identification information,
organs and tissue recovered,
date of recovery, all test
results, current hospital
history, past medical and
social history,
pronouncement of death,
consent and next-of-kin
information
10 years;
Records are also
retained in the
Organ
Procurement and
Transplantation
Network Data
System for 25
years following
the known death
of the organ
recipient.
42 C.F.R. §
486.330(c);
PC.17.20(6); 42
U.S.C. § 274,
http://www.hrsa.gov/
privacyact/sorn/
09150055.htm
Embryo
Laboratory
Records
Policies and procedures;
personnel employment,
training evaluations, and
continuing education
activities; and quality
management activities
10 years beyond
the date of final
disposition or
disposal of all
specimens
obtained during
each patient’s
ART cycle
Fertility Clinic
Success Rate and
Certification Act of
1992, 64 Fed. Reg.
39373, 39391 (July
21, 1999) (codified
at 42 USC § 263a-
1). The codification
does not include the
10 year record
retention period.
Many states have
specific record
retention policies, it
appears Wis. does
not.
Radiation Sources Records of the receipt,
transfer and disposal of all
sources of radiation
3 years following
transfer or
disposal of the
radiation transfer
or disposal
Wis. Admin Code §
HFS 157.06(1)
Radioactive
Material other
than Source
Material
Records showing testing for
leakage, other tests,
installation, servicing and
removal of radioactive
material, its shielding or
containment. Including dates
and name person performing
testing, installation or removal
3 years from the
event or until the
event or until the
device is
transferred or
disposed of.
Wis. Admin Code §
HFS
157.11(2)(b)3.d
Records of
Transfer of
Radioactive
material in
devices
Record showing the name,
address and point contact for
each licensee to whom the
radioactive material is
transferred.
5 years from date
of transfer
Wis. Admin Code §
HFS
157.13(4)(d)5.h







Page 17 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
Records of
Occupational
Radiation
Exposure
Records used in preparing
the exposure report.
3 years after the
record is made
Wis. Admin Code §
HFS 157.22(5)(f)
Department’s
Occupational
Radiation
Exposure Form
Until licensure or
registration is
terminated or
term of
employment plus
30 years,
whichever is
longer.
Wis. Admin Code §
HFS 157.22(5)(f)
Records of the
radiation
protection
program and
audits
3 years after
record is made
Wis. Admin Code §
HFS 157.31(2)(b)
Record of dose of
radiation received
by individual
members of the
public and
surveys of
patients and
human subjects
Until licensure or
registration is
terminated
Wis. Admin. Code
§§ HFS
157.31(8)(a),
157.71(16)
Record of testing
entry control
devices for very
high radiation
areas
3 years after the
record is made
Wis. Admin. Code §
HFS 157.31(10)(b)
Records of
administrative
actions taken by
the licensee’s
management
Requests for license
application renewals or
amendments, authorizations
to work as an authorized
user, nuclear pharmacist or
medical physicist
5 years Wis. Admin. Code §
HFS 157.71(1)(a)
Records of
Radiation
Protection
Program changes
not requiring
departmental
approval
Include a copy of the old and
new procedures, the effective
date of the change, and
management signature
approving the change.
5 years Wis. Admin. Code §
HFS 157.71(2)







Page 18 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
Records of
Written Directives
Procedures for the
administration of >1.11
Megabequerel of I-131
sodium iodide, therapeutic
doses of unsealed radioactive
material or radiation from
radioactive material
3 years Wis. Admin. Code §
HFS 157.71(3)
Records of
medical events or
records of doses
to an embryo,
fetus or nursing
child
Include the licensee's name,
the name of persons
involved, the social security
number of the subject to the
event, the effect on an
individual, actions taken to
prevent recurrence, whether
affected individuals were
identified, and if not notified,
why not.
3 years Wis. Admin. Code
§§ HFS 157.71(4),
(5)
Records of
Calibration of
Instrumentation,
Survey
Instrumentation
and
Brachytherapy
Sources
Calibration of instruments
used to measure the activity
of unsealed radioactive
materials prior to their
administration to a patient.
The survey instrument used
to show compliance with the
requirements for the medical
use of radioactive material
must be calibrated at least
every 13 months.
3 years Wis. Admin. Code §
HFS 157.71(6); Wis.
Admin Code § HFS
157.31(3)(a); Wis.
Admin. Code § HFS
157.71(7); Wis.
Admin. Code § HFS
157.71(18)
Records of
Dosage of
Unsealed
Radioactive
Materials
3 years Wis. Admin. Code §
HFS 157.71(8)
Records of Sealed
Sources and
Brachytherapy
Sources
Records of leak tests, semi-
annual physical inventory of
these sources and
brachytherapy source
accountability
3 years Wis. Admin. Code
§§ HFS 157.71(9),
(17)
Reports of test
results for leaking
or contaminated
sealed sources
3 years after
disposal or repair
of source
Wis. Admin Code §
HFS 157.24(7)
Records of tests
for leakage or
contamination of
sealed sources
Inconsistent with 157.71(9)
which requires 3 years only.
5 years after test
date
Wis. Admin Code §
HFS 157.31(4)







Page 19 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
Records of Survey
for Ambient
Radiation
Exposure
Surveys at the end of each
day of all areas where
radioactive drugs requiring a
written directive have been
prepared or administered
3 years Wis. Admin. Code §
HFS 157.71(10)
Records of
release of persons
containing
radioactive drugs
or implants and
copies of letters
permitting use of
radioactive
material at a
client’s address
3 years after the
release date or
last provision of
service
Wis. Admin. Co7de
§§ HFS 157.71(11),
(12)
Records of
Disposal of
licensed materials
3 years Wis. Admin. Code §
HFS 157.71(13)
Records of
Contaminant
concentration
3 years Wis. Admin. Code §
HFS 157.71(14)
Records of
instruction and
training
3 years Wis. Admin. Code §
HFS 157.71(15)
Records of
Dosimetry
Equipment

Intercomparison, comparison
and calibration of dosimetry
equipment
Duration of the
license
Wis. Admin. Code §
HFS 157.71(20)
Records of
Installation,
Maintenance,
Adjustment
Repair and
Calibration

Remote afterloader units,
teletherapy units and gamma
stereostatic units
3 years Wis. Admin. Code
§§ HFS 157.71(19),
(21)
Records of
Periodic Spot
Checks of
teletherapy units,
afterloader units
and gamma
stereostatic units
3 years Wis. Admin. Code
§§ HFS 157.71(22),
(23), (24)







Page 20 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
Records of
Surveys of
therapeutic
treatment units
Duration of unit
use
Wis. Admin. Code §
HFS 157.71(26)
Records of 5 year
inspections for
teletherpy and
gamma
stereostatic
radiosurgery units
Duration of unit
use
Wis. Admin. Code §
HFS 157.71(27)
Records of Decay
of Strontium-90
Sources for
Ophthamalic
treatments
The life of the
source
Wis. Admin. Code §
HFS 157.71(28)
PATIENT RESOURCES
Compliments Written documents
complimentary of the
treatment and services
provided to patients
3 years
Incident Reports These are copies of the
incident reports received in
the Safety Department.
Originals are maintained by
Safety & Employee Health –
see below.
3 years
Medical
Assistance
Applications
These are copies of MA
applications for benefits. The
counties retain the original
applications.
3 years
Patient
Complaints –
Database
Database of all patient
complaint information.
Permanent
Patient
Complaints -
Adults
Written patient complaints
with respect to adult patients.
4 years
(Statute of
Limitations plus 1
year)
WI Stats. 893.54
WI Stats. 893.55
Patient
Complaints –
Minors

Written patient complaints
with respect to minor patients
– Scanned document files.
Age of majority
plus 3 years

Pharmaceutical
Assistance
Copies of applications for
medication assistance filed
1 year







Page 21 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
Applications with participating
pharmaceutical companies.
Company maintains original
application.
PHARMACY (Pharmacy Assets transferred to UWHCA 11/1/2005)
Rebate Contracts Contract term
plus 6 years
WI Stat. 893.43
Pharmacy
Contracts
Contract term
plus 6 years
WI Stat. 893.43
Prescriptions
Dispensed
5 years
Prescription
Orders

5 years
PURCHASING
Inventories 7 years
Packing Slips 3 months
Purchase Orders Capital expenditure items 10 years
Other 4 years
Purchase
Requisitions
2 years
Receiving Reports 2 years
Returned Goods
Credits
2 years
PROVIDER CONTRACTS
Contracts Contract Term
plus 6 years
Wis. Stat. 893.43
RECORDS MANAGEMENT

Record
Destruction
Documentation
Indefinite
Records Inventory 1 year
Record
Management
Procedures
Indefinite







Page 22 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
SAFETY & EMPLOYEE HEALTH
Hazardous
Materials
Exposure Records
Term of
employment plus
30 years
29 CFR 1910.1020
Fire Alarm
Inspection and
Drills
2 years per Fire
Code
NFPA 72
Clinic Cleaning
Log
Disinfection of patient care
areas
3 years (no
standard)

Instrument
Processing Logs
Autoclave, Glutaraldehyde 3 years
(consulted with
professional
associations – but
no standard was
mentioned

Log for
Temperature-
Sensitive
Medications
3 years
(recommended
by CDC)

Safety Inspection
Checklist
3 years (see
policy and items)

Medical Waste
Manifests
5 years – Per
DNR
DNR Chapter NR
526
Material Safety
Data Sheets
30 years – Per
OSHA (return old
sheets to
EHIC/Safety for
retention)
29 CRF 1910.1200
Patient Care
Equipment
Inspections
2 years
(consulted with
vendor – no
standard for
retention)

Bloodborne
Pathogens/Sharps
Injury Log
5 years 29 CFR 1910.1030
Sharps Injury
Record (incident
report) / Hepatitis
B Vaccination
Record / Exposure
Record (incident
Duration of
employment +30
years
29 CFR 1910.1030







Page 23 of 23
TYPE DESCRIPTION RETENTION
PERIOD
CITATION
report)
Radiation
Exposure
Duration of
employment + 30
years
29 CFR 1910.1020
Ergonomic Injury
(Incident Report)
Duration of
employment + 30
years
29 CFR 1904
Workplace
Violence (Incident
Report)
Duration of
employment + 30
years
29 CFR 1904
Tuberculosis Skin
Test & Exposure
Records
Duration of
employment + 30
years
29 CFR 1910.1020
OSHA Training
Documentation
New Employee and Clinical
Orientations
3 years 29 CFR 1910
General Industry