Common Banks Title Payroll Location Finance, various departments Legal Authority Consent of individuals and as necessary to the proper administration of payroll for employees Information Maintained Name, address, SIN, benefits, tax contributions, pension contributions, employee salaries, deductions, time away, banking information, paid hours Uses Long and short term fiscal planning, Users Management Individuals in Bank Employees, previous employees Retention & Disposal 7 Years Common Banks Personnel Files Title Personnel Files Location Human Resources, various management offices Legal Authority Consent of individual, Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 75 and as necessary to the proper administration of employment matters Information Maintained Names, date of birth, contact information, education information, Opinions about performance, assessments, evaluations, time off requests, emergency contacts, job applications information, resumes, grievance information, criminal record checks, pension and benefit data, WSIB records, disciplinary actions, employment history, marital status, attendance and leave information, employment contracts, designated substance exposure records Uses Human Resources program administration, departmental management Users Human Resources staff, managers Individuals in Bank Employees, paid students, post-doctoral and research fellows, retirees Retention & Disposal 3 years after creation date for general employment records, 40 years for occupational health and safety, and workplace safety and insurance records. Common Banks Event Tracking Reports Title Event Tracking Reports Location Quality Safety & Best Practice, various management offices Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2), as necessary to the proper administration of risk management program Information Maintained Name, date of birth, contact information, communication related to event, details and description of the event, action plans Uses Event investigation and resolution Users Patient Safety Officer & Risk Manager; Director, Quality, Safety & Best Practice; Appropriate Leadership Individuals in Bank Employees, volunteers, students, clients, family members Retention & Disposal Until follow-up complete plus 2 years Corporate Services Artists Information Title Artist information Location Culture, Arts & Innovation administration Legal Authority Consent of individuals and as necessary to the proper administration of the art collection. Information Maintained Names, contact information, tax receipts, correspondence Uses For collection/retention of art Users Art Administrator Individuals in Bank Artists who have donated works to Baycrest Retention & Disposal 1 year after date of last use Corporate Services Music therapy client records Title Music therapy client records Location Music Therapy Legal Authority Consent of individuals Information Maintained Names, medical history, consent for video/audio recording, referrals Uses Provision of care to patients Users Music Therapist Individuals in Bank Apotex residents, hospital patients, clients of the Day Centre for Seniors Retention & Disposal 10 years after discharge or death Education Student placement registration Title Student placement registration Location Academic Education Legal Authority Consent of individuals, Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 75, and as necessary to the proper administration of student education Information Maintained Name, discipline, contact information, emergency contacts, educational , institution, program, student number, evaluations, testimonials, criminal reference checks, immunization information. Uses To administer student placements Users Student Placement Coordinator Individuals in Bank Students Retention & Disposal 1 year after date of last use eHealth Patient Record (paper chart and meditech) Title Patient Record (paper chart and meditech) Location Health Records Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2) Information Maintained Name, names of substitute decision maker, OHIP number, contact information, age, ethnic origin, marital status, test results, prescriptions, diagnoses, religion, status, medical opinions, plan of care, billing information Uses Record of care Users Individuals in a patient’s circle of care, health records staff Individuals in Bank Patients Retention & Disposal 10 years after discharge or death eHealth Death Registry Logs Location Health Records Legal Authority Necessary to the proper administration of a health facility Information Maintained Name of patient, cause of death, date and place of death Uses Reports deaths Users Nursing staff, Health Records staff, Individuals in Bank Previous patients Retention & Disposal 10 years after discharge or death eHealth Access and Privacy tracking information Title Access and Privacy tracking information Legal Authority Consent if individuals, Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. F.31, s. 39(1)(b) and as necessary to the proper administration of access to information requests and privacy obligations Information Maintained Names, contact information, date of birth, descriptions of privacy breaches, access to information requests/letters, consent forms , access forms, access to health records requests Uses Resolve privacy breaches, respond to access requests Users Chief Privacy Officer, Freedom of Information Coordinator, Health Records department Individuals in Bank Some patients, substitute decision makers, individual requesters Retention & Disposal 7 years after superseded or, as applicable, after appeal rights expire Human Resources Recruitment and Hiring Title Recruitment and Hiring Location Human Resources Legal Authority Consent of individual, Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 75 and as necessary to the proper administration of employment matters Information Maintained Job applications, Resume, contact information, references, may include records related to application screening and acceptance/rejection of candidates Uses Hiring Users Human Resources staff Individuals in Bank Individuals who have applied for positions with Baycrest Retention & Disposal 3 years after creation date Human Resources Information System Title Human Resources information system Location Human Resources, eHealth Legal Authority Consent of individual, Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 75 and as necessary to the proper administration of employment matters Information Maintained Name, address, email address, telephone number, date of birth, education information, emergency contact information, names and dates of birth of beneficiaries and dependants, SIN, salary, disciplinary actions, pension data, Employee pay, performance and employment details Uses HR program administration Users Human Resources and Payroll staff Individuals in Bank Employees, paid students, post-doctoral and research fellows, retirees Retention & Disposal 3 years after creation date for general employment records Human Resources Personnel Files Title Human Resources Personnel Files Location Human Resources Legal Authority Consent of individual, Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 75 and as necessary to the proper administration of employment matters Information Maintained Names, date of birth, contact information, education information, Opinions about performance, assessments, evaluations, time off requests, emergency contacts, job applications information, resumes, grievance information, criminal record checks, pension and benefit data, WSIB records, disciplinary actions, employment history, marital status, attendance and leave information, employment contracts, designated substance exposure records. . Uses Human Resources program administration, departmental management Users Human Resources, applicable manager as appropriate Individuals in Bank Employees, paid students, post-doctoral and research fellows, retirees Retention & Disposal 3 years after creation date for general employment records, 40 years for occupational health and safety, and workplace safety and insurance records Legal Affairs Client/Family Records Title Client/Family Records Location Office of Director, Legal Affairs and law clerk Legal Authority As necessary to the proper administration of institution’s legal affairs Information Maintained Client name, medical/psychiatric status, financial information, address, phone numbers, views, opinions, legal opinions, correspondence, marital or family status Uses To address legal issues facing Baycrest Users Director, Legal Affairs, law clerk, administrative assistant Individuals in Bank Patients, families, visitors Retention & Disposal 1 year after date of last use Occupational Health & Safety Parklange System/Employee Health Files Title Parklange System/Employee Health Files Location Occupational Health & Safety, eHealth Legal Authority Consent of Individuals, Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2), as necessary to the proper administration of the occupational health and safety Information Maintained Employee health record Uses Documentation of employee health issues and incidents Users Occupational Health & Safety nurses and one administrator Individuals in Bank Employees Retention & Disposal 40 years Ombudsperson’s Client Files Title Ombudsperson’s Client Files Location Office of Ombudsperson Legal Authority Consent of individuals, Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2), as necessary to the proper administration of ombudsperson functions, Information Maintained Name, marital/family status, telephone number, address, email address, age, complaints/concerns related to Baycrest’s services/programs Uses Compliant follow up resolution Users Ombudsperson, administrative secretary Individuals in Bank Patients, residents, employees and family members Retention & Disposal 2 years from the date of file closure Or, if serious, until t finally resolved by settlement, judgment expiry of appeal period Organizational Effectiveness Tuition assistance applications Title Tuition assistance applications Location Organizational Effectiveness Legal Authority Consent of individuals and as necessary to the proper administration of tuition assistance program Information Maintained Employee name, home phone number, copy of void cheque, education information, course of study, final grade Uses Tuition assistance determination Users Organization Effectiveness and Finance staff Individuals in Bank Employees who have applied for tuition assistance Retention & Disposal One year after last use. Strategic Advancement & Stakeholder Relations Media consent form Title Media consent form Location Public Affairs office Legal Authority Consent of individuals Information Maintained Name, contact information Uses To obtain consent for media interviews, photos and videos Users Director, Public Relations Individuals in Bank Interviewees Retention & Disposal 1 year after date of last use Support Services - List of Food & Nutrition Services Customers Information Title List of Food & Nutrition services customers information Location Food & Nutrition Services Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2) Information Maintained Name, patient or resident location, dietary requirements Uses Meal preparation Users Food & Nutrition staff Individuals in Bank Patients Retention & Disposal 7 years Support Services Wandering Client Records Title Wandering client records Location Communications Desk Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2) and as necessary to the proper administration of risk management and client safety Information Maintained Name, previous incidents, room number, patient description: photo, age, height, weight, eye colour, identifying marks Uses To monitor, safeguard and retrieve wandering clients Users Communications desk staff Individuals in Bank Wandering clients Retention & Disposal 2 years Volunteer Services - Volunteer Information Files Title Volunteer Information Files Location Volunteer Services Legal Authority Consent of individuals, Long-Term Care Homes Act, 2007, S.O. 2007, c. 8, s. 75, and as necessary to the administration of the volunteer program. Information Maintained Name, telephone number, address, date of birth, resumes, education and employment history, languages spoken, age, TB test results, hours worked, criminal record screening Uses Volunteer Services administration, assigning volunteers Users Volunteer Services staff Individuals in Bank Volunteers Retention & Disposal 1 year after date of last use Research Participant Database Title Research Participant Database Location Web server Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s.36(1)(d) and consent of individuals Information Maintained Subject ID, status notes, images/photos, group information, source, source type, participation date, availability (scheduling), methods of contact, participation frequency, date of birth, occupation, gender, handedness, languages spoken, music, education, weight, metal, condition, neurological information, disease rating, psychological information, medication, memory issues, research test data. Uses To compile research data about study participants Users All Research Ethics Board approved investigators and research testing personnel. Individuals in Bank Consented research participants (Baycrest staff, research staff, students, Baycrest patients, members of the community). Deidentified. Retention & Disposal 25 years Research Contact Information Database Title Contact Information Database (Research) Location Encrypted excel file, on independent Research server Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1)(d) and consent of individuals Information Maintained Research subject ID, name, license plate, address, telephone numbers, email address, address, Dx, MMSE score, MoCA score, BNA score Uses Contact information for all participants in the online research participant database Users Subject coordinator, research & subject assistant, research staff Individuals in Bank Consented research participants (Baycrest staff, research staff, students, Baycrest patients, members of the community) Retention & Disposal 25 years Research - Stroke Patient Recovery Research Database (SPReD) Title Stroke Patient Recovery Research Database (SPReD) Location RRSI Sever Room Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s.36(1)(d) and consent of individuals Information Maintained Postal code, telephone numbers, Integrated Neuro-Cognitive Assessment System (INCAS) ID, health card number. Uses Data is used to uniquely assign internal IDs to subjects and to look for common subjects between multiple projects. Users Researchers of the Centre for Stroke Recovery Individuals in Bank Patients seen by neurologists using INCAS who have agreed to be contacted as research subjects. Retention & Disposal 25 years Clinical and Residential - Ethics Referral Forms Title Ethics referral forms Location Clinical Ethics, administration Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2), and as necessary to the proper administration of clinical ethics program Information Maintained Names, contact information, physician, background, age, sex, admission number, room number, health card number, falls risk assessment score, height, weight, reason for referral Uses Resolve ethical issues at Baycrest Users Ethics office administrative staff Individuals in Bank Patients and family Retention & Disposal One year after last use Infection Prevention & Control - Infection tracking files Title Infection tracking files Location Infection Prevention & Control Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2) Information Maintained Infection status of clients Uses Infection control surveillance and resolution Users Infection Prevention & Control staff Individuals in Bank Patients Retention & Disposal 7 years Health Disciplines - Records of Inpatient Dispensing & Prescriptions Title Records of inpatient dispensing & prescriptions Location Pharmacy Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2) Information Maintained Patient’s name, address, OHIP number, telephone numbers, account number, ordering physicians, prescription Uses Record of medication dispensed Users Pharmacy staff Individuals in Bank Hospital patients Retention & Disposal 2 years Health Disciplines - Film Library Title Film Library Location Diagnostic Imaging Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2) Information Maintained Names, health card number, X-Rays Uses Retain and manage X-Rays Users Diagnostic Imaging staff Individuals in Bank Patients who had X-Rays Retention & Disposal 5 years after day on which the image is created. Health Disciplines - Access Requests Title Access Requests Location Diagnostic Imaging administration Legal Authority Consent of individuals and as necessary to the proper administration of access to information requests Information Maintained Access request for diagnostic images: name, health card number, date of birth, requested records Uses To respond to access to information requests Users Diagnostic imaging staff, health records staff Individuals in Bank Individuals who have made requests for information Retention & Disposal 7 years after superseded Health Disciplines - Dosimeter Reports Title Dosimeter Reports Location Diagnostic Imaging Legal Authority Occupational Health and Safety Act, R.R.O. 1990, Reg. 861, s. 12(1) Information Maintained Amount of radiation exposure of staff Uses Ministry of Health and Long Term Care auditing Users Diagnostic Imaging staff, MoHLTC Individuals in Bank Diagnostic Imaging staff Retention & Disposal 3 years Health Disciples - Physiotherapy Evaluation Database Title Physiotherapy evaluation database Location Physiotherapy administration offices Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2) Information Maintained Name, gender, health information related to patient’s condition, attendances, satisfaction ratings. Uses Program management and evaluation Users Physiotherapists Individuals in Bank Patients who participated in self-management programs Retention & Disposal 10 years after discharge or death Health Disciples - Lab Test Results Title Lab test results Location Laboratory administration Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2) Information Maintained Names, address, telephone number, OHIP number, test results Uses Provision of care Users Laboratory technicians Individuals in Bank Staff, patients Retention & Disposal 10 years after discharge or death Quality, Safety & Best Practice - Event Tracking Reports Title Event tracking reports Location Quality Safety & Best Practice, various management offices Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2) and as necessary to the proper administration of risk management program Information Maintained Name, date of birth, contact information, communication related to incident, details and description of incident, Uses Incident investigation and resolution Users Patient Safety Officer & Risk Manager; Director, Quality, Safety & Best Practice; appropriate leadership Individuals in Bank Employees, volunteers, students, clients, family members Retention & Disposal Until follow-up complete plus 2 years Apotex Centre, Jewish Home for the Aged (long-term care home) - Resident Information Title Apotex Resident Information Location Apotex administration office Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2), and as necessary to the proper administration of long-term care home Information Maintained Resident ID, name, family names, contact information, medical history, prescriptions. Uses Provision of care Users Apotex nursing staff, circle of care Individuals in Bank Apotex residents Retention & Disposal One year after last use Terraces of Baycrest - Terraces Resident Information Title Terraces Resident Information Location Terraces health centre Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2), consent of individuals, and as necessary to the proper administration of a retirement home. Information Maintained Name, resident photo directory, floor listings, list of admissions and discharges, care plans, medical charts, intake assessments, home safety assessments, billing information, name, medical history, family contact information, medical opinions, prescriptions, financial information Uses Provide care for and safeguard clients Users Terraces administrative staff Individuals in Bank Terraces residents Retention & Disposal 7 years from last date of residency Terraces of Baycrest - Lifeline Monitoring Information Title Lifeline Monitoring Information Location Terraces administration office Legal Authority Personal Health Information Protection Act, S.O. 2004, c. 3, Sched. A, s. 36 (1) and (2) and consent of individuals. Information Maintained Name, apartment number, telephone number, tracking information Uses To provide information to monitoring company Users Administration office staff members Individuals in Bank Terraces residents Retention & Disposal 7 years from last day of person’s residency