Unit Policy
Title
Department of Orthopaedics: Policy on Record Retention
Introduction
Purpose
The purpose of this policy is to define requirements for Record Retention.
Scope
This policy applies to all Department of Orthopaedic employees that use or maintain records for administrative and clinical purposes.
Policy
Policy Statement
In an effort to establish consistency and regulatory compliance with our records management, the Department of Orthopaedics is establishing a records retention and disposition policy. This policy will help us to establish efficient methods to maintain and preserve records that document the activities and history of the department, clinical patient information, as well as ensure the proper disposal of official records. Records that contain sensitive information must be stored in a secure area, such as a locked room or locked filing cabinet, or in a password protected electronic file or secure server. Additionally, records that contain sensitive information must be destroyed in a way that ensures that confidentiality of these records will be preserved.
The following information was excerpted from the University’s Record’s Retention and Disposition Schedule.
Administrative
The Department currently has paper files on all SPA and EPA employees both past and present. These files will be transferred to an electronic system in the near future and housed on the J drive under Human Resources (assigned access). Until that transition occurs, all paper files are to be secured in a locked file cabinet. These files are for departmental use only and referred to as reference copies hereafter. The original personnel records are maintained by the University Human Resources office.
Use
All information contained in personnel and patient files is considered confidential.
Exempt from the State Personnel Act (EPA) Non-Faculty Administrative Records - Administrative records documenting EPA Non-Faculty related issues involving annual leave exceptions, position classifications, and other related topics. This series may include but is not limited to: policies, procedures, reports, and related documentation and correspondence.
Disposition Instructions: Permanent. Transfer to employee’s main personnel file.
Exempt from the State Personnel Act (EPA) Personnel Records - Personnel records of EPA employees, defined as all employees, including student employees and post-doctoral fellows, exempt from the State Personnel Act. This series may include but is not limited to: applications; contracts; resumes and vitae; records concerning promotions, demotions, and transfers; personnel action forms; salary data and history; records concerning termination of employment; verifications and credentials; copies of licenses and certifications; records concerning adjunct faculty appointments; records concerning employee’s aggregate service history; and related documentation and correspondence.
Confidentiality: Comply with applicable provisions of G.S. 126-22, 126-23, and 126-24 regarding confidentiality of personnel records. Comply with applicable provisions of 20 U.S.C. 1232g (Family Educational Rights and Privacy Act (FERPA) of 1974) regarding confidentiality of student records.
Office of Record: Office of Human Resources, Employee Records; Chancellor’s Office; Provost’s Office. Records are destroyed in the HR office 75 years after separation or termination.
REFERENCE COPY: Disposition Instructions: a. Transfer Hiring Credentials Check Form 3 years after termination of employment or transfer from unit to employee’s main personnel file held by Office of Record as listed above. b. Destroy in office remaining records 5 years after termination of employment, transfer from unit, or end of appointment.
Subject to the State Personnel Act (SPA) Personnel Records - Personnel records of all employees subject to the State Personnel Act. This series may include but is not limited to: applications; resumes and vitae; records concerning promotions, demotions, and transfers; personnel action forms; salary data and history; records concerning termination of employment; verifications and credentials; copies of licenses and certifications; records related to employee’s aggregate service history; and related documentation and correspondence.
Confidentiality: Comply with applicable provisions of G.S. 126-22, 126-23, and126-24 regarding confidentiality of personnel records.
Office of Record: Office of Human Resources, Employee Records. Records are destroyed in the HR office 75 years after separation or termination.
REFERENCE COPY: The schools, departments, or units. Disposition instructions: Destroy 5 years after employee separation.
Disciplinary Records - Records documenting disciplinary actions brought against University employees. This series may include but is not limited to: reports, forms, and related documentation and correspondence.
Confidentiality: Comply with applicable provisions of G.S. 126-22, 126-23, 126-24, regarding confidentiality of personnel records.
Disposition Instructions: Destroy in office 5 years after final resolution. Destruction after final resolution may occur earlier if permitted by state law, regulations, or policy.
REFERENCE COPY: Disposition Instructions: Destroy in office when reference value ends.
Dispute Resolution and Grievance Records - Records documenting the dispute resolution and staff grievance policies programs at the University. This series may include but is not limited to: forms, statements, responses, hearing and conference notes, decisions, and related documentation and correspondence.
Confidentiality: Comply with applicable provisions of G.S. 126-22, 126-23, and 126-24, regarding confidentiality of personnel records.
Disposition Instructions: Destroy in office 3 years after final resolution of grievance or dispute.
REFERENCE COPY: Disposition Instructions: Destroy in office upon resolution of grievance.
Duty Assignment and Performance Evaluation and Management Records - Records documenting the daily work duties, tasks, goals, and development of University employees that are also used to evaluate his or her performance. This series may include but is not limited to: work plans, assignments, and reports; development plans and performance evaluations; warning letters and counseling memos; and related documentation and correspondence.
Office of Record: The schools, departments, or units.
Confidentiality: Comply with applicable provisions of G.S. 126-22, 126-23, 126-24, regarding confidentiality of personnel records.
Disposition Instructions: Destroy in office official copies after 3 years if no litigation, claim, audit, or other official action involving the records has been initiated. If official action has been initiated, destroy in office after completion of action and resolution of issues involved.
REFERENCE COPY: Disposition Instructions: Destroy in office after 3 years.
Employee Verification Records - Records documenting the verification process for appointment, employment, or other related verifications. This series may include but is not limited to: reports, and related documentation and correspondence.
Confidentiality: Comply with applicable provisions of G.S. 126-22, 126-23, and 126-24 regarding confidentiality of personnel records.
Disposition Instructions: Destroy in office 5 years after completion of verification.
Residency Program Records
Accreditation Records. Records documenting the accreditation process for the University and/or its schools, colleges, programs, and departments by the Southern Association of Colleges and Schools (SACS) or other accreditation bodies. This series may include but is not limited to: reports, questionnaires, guides, and related documentation and correspondence.
Disposition Instructions: a. Permanent for final report. Transfer 1 copy of final report to the custody of University Archives after accreditation process ends. b. Destroy in office remaining records when reference value ends.
Activities and Events Records. Records documenting activities and events that are initiated or sponsored by the University, and the efforts of individual units to provide informative sessions, short courses, workshops, training programs, excursions, and celebratory events for the University community. This series may include but is not limited to: planning materials, reports, promotional and publicity materials, schedules, bulletins, memorandums, circulars, invitations, announcements, press releases, news clippings, presentation materials, registration and attendance lists, evaluations, photographs, video and audio recordings, and related documentation and correspondence.
Disposition Instructions: a. Permanent for planning materials, reports, promotional and publicity materials, press releases, photographs, audio and video recordings, and schedules of speakers and activities. Transfer to the custody of University Archives after 5 years. b. Destroy in office remaining records after 5 years.
Development and Alumni Records
Alumni Association Records - Records documenting the University’s and individual units’ alumni associations. This series may include but is not limited to: publications, reports, and related documentation and correspondence.
Disposition Instructions: Permanent. Transfer records to the custody of University Archives after 5 years, or when reference value ends.
Alumni Lists -Lists of names, addresses, phone numbers, and other contact information of University alumni. This series may include but is not limited to: lists.
Disposition Instructions: Destroy in office when superseded or obsolete.
Donor and Prospect Records - Records documenting information on individual donors and prospective donors. This series may include but is not limited to: files on donors and prospects that contain contact information, fund names, fund numbers, biographical data, financial data, scholarship or endowment documentation, notes, and related documentation and correspondence.
Confidentiality: Comply with applicable provisions of State and federal law regarding confidentiality of taxpayer information.
Disposition Instructions: Destroy in office when reference value ends.
Financial Records
Accounts Payable Records - Records documenting the status of accounts in which the University owes money to firms or individuals. This series may include but is not limited to: statements, invoices, purchase orders, and related documentation and correspondence.
Disposition Instructions: Destroy in office after 3 closed fiscal years, if no litigation, claim, audit, or other official action has been initiated. If official action has been initiated, destroy in office after completion of action and resolution of issues involved.
REFERENCE COPY: Disposition Instructions: Destroy in office after 2 years.
Accounts Receivables and Cash Receipts Records - Records documenting payment and status of accounts in which money is owed to the University by firms or individuals. This series may include but is not limited to: purchase orders, checks received for repayment, school refunds, lender claim repurchases and refunds, insufficient funds notices, and related documentation and correspondence.
Disposition Instructions: Destroy in office after 5 years, if no litigation, claim, audit, or other official action has been initiated. If official action has been initiated, destroy in office after completion of action and resolution of issues involved.
REFERENCE COPY: Disposition Instructions: Destroy in office after 2 years.
Related Requirements
External Regulations
Contact Information
Primary Contact
Name: James O. Sanders, MD - Chair of Orthopaedic Surgery
Telephone: 919-966-9072
Email: james_sanders@med.unc.edu
Other Contacts
Name: Paul Marini, MHA, FACHE - Associate Chair of Administration
Telephone: 919-843-9382
Email: Paul_Marini@med.unc.edu