(A)
Purpose
The purpose of this rule is to
establish economical and efficient methods related to the creation,
utilization, maintenance, retention, preservation, and disposition of records
and to document the methods necessary to comply with the northeast Ohio medical
university (NEOMED) records retention schedule.
(B)
Scope
This rule applies to all individuals
involved in creating, receiving, accessing, using, or maintaining
records.
(C)
Definitions
(1)
"Departmental
archive" refers to the physical and/or digital space designated by each
university department and office for the appropriate preservation of permanent
records.
(2)
"Departmental records manager" refers to the university
employee from each department or office of record origin designated to assist
with the university's compliance with regulatory records management
requirements and facilitates the appropriate retention and disposition of
records.
(3)
"Disposal method" refers to the appropriate means of
destruction based upon the university data within a record and the medium (i.e.
Electronic, paper) in which it exists. These disposal methods include, but are
not limited to, shredding, recycling, electronic deletion or destruction,
wastebasket disposal, and transfer to the respective departmental
archive.
(4)
"Disposition" refers to what is finally done with a
record, whether it be ultimate destruction or transfer.
(5)
"Document
imaging" refers to the conversion of paper-based records to digital, imaged
electronic records.
(6)
"Electronic record" refers to any record created,
generated, sent, communicated, received or stored by electronic means. (e.g.,
electronic mail ("email"), databases, document images, word processing
documents and spreadsheets and material secured through blockchain
technology).
(7)
"Legal or litigation hold" refers to a restriction on a
record that exists as a result of current or anticipated litigation, audit,
government investigation, or other such matter that suspends the normal
disposition or processing of records.
(8)
"Records
retention schedule" refers to an institutional resource that provides guidance
to the university community on the appropriate retention and disposition of
records.
(9)
"Non-record" refers to any document, device, or item,
regardless of physical form or characteristic, including an electronic record
that does not meet the "record" definition (e.g., personal notes to assist in
recalling events, copies of records, or library materials kept for
reference).
(10)
"Permanent record" or "archival record," refers to a
record that is retained permanently by the university within a departmental
archive for its significant administrative, legal, fiscal or historical
value.
(11)
"Public record" refers to records that are subject to
release under the Ohio public records law.
(12)
"Record" refers
to any document, device, or item, regardless of physical form or
characteristic, including an electronic record, that is created, received by,
or comes under the purview of the university, which serves to document the
organization, its functions, policies, decisions, procedures, operations or
other activities of the university (e.g., financial records such as
requisitions, purchase orders, and invoices; administrative records such as
annual reports, university bylaws, and policies; and publications and other
items issued by the university.
(13)
"Record
category" refers to a group of record series having common characteristics and
retention periods and is listed within the NEOMED records retention
schedule.
(14)
"Record series" refers to a group of related records
evaluated as a group for retention and disposition purposes.
(15)
"Retention
period" refers to the minimum period that records should be kept in a certain
location or format based on its administrative, legal, fiscal, or historical
value.
(16)
"Transient record" or "transitory record" refers to a
record which is not of long-term value and is not needed to preserve the
actions of the university, but exist for short-term usage and/or convenience.
(e.g., drafts that are not superseded or updated by other records; phone slips
or voicemail; and meeting notices).
(17)
"University
data" as used and defined within rule
3349-9-15 of
the Administrative Code.
(D)
Rule
statement
(1)
Records management program
(a)
NEOMED has
established a records management program to comply with laws regarding the use
of efficient and economical management methods for the creation, utilization,
maintenance, retention, preservation, and disposition of records and to
document the methods necessary to comply with the NEOMED records retention
schedule.
(b)
NEOMED's records management program shall be
coordinated by the office of compliance and risk management, along with
university departments, to ensure compliance with applicable laws and
university policies.
(c)
Records are the property of NEOMED and the state of
Ohio and shall not be permanently removed or destroyed except in accordance
with the NEOMED records retention schedule and its associated
procedures.
(d)
Public records maintained by the university must be
made available for public inspection pursuant to the Ohio public records
law.
(e)
Each university employee is responsible for ensuring
that records (including electronic records) within their area(s) are maintained
in such a way that they can be identified and retrieved
efficiently.
(f)
All university employees are required to comply with
this rule regarding records management.
(2)
Record
retention
(a)
Records must be managed and retained if there is a legal, financial,
administrative, or historical requirement to do so, as set forth in the records
retention schedule.
(b)
The amount of time that the university must retain
records depends upon the legal, fiscal, administrative, and/or historical
informational value of the record.
(c)
Transient records
are not subject to retention beyond the purpose for which they are created and
can be disposed at that time; however, if retained, transient records are
subject to Ohio public records act.
(d)
All university
employees must familiarize themselves with the NEOMED records retention
schedule and understand what records they create and/or receive and are
required to manage.
(e)
University departments and offices shall conduct a
periodic inventory of their records and align them to the NEOMED records
retention schedule.
(f)
If an employee identifies records for which there is no
established retention period, the employee should contact their departmental
records manager. Each departmental records manager will consult with the office
of compliance and risk management to determine the appropriate retention
periods and disposal method for a given records series.
(3)
Record
disposition
(a)
Disposition of records shall be done in a timely manner and
in accordance with the NEOMED records retention schedule.
(b)
Prior to
disposition, a department or office needs to confirm that the minimum retention
period of the records has expired and that there is no legal or litigation hold
on the records.
Records that have been placed under a
legal or litigation hold by the office of the general counsel must not be
disposed of or modified in any manner until the action is adequately resolved
or the university general counsel has directed otherwise.
(c)
Upon
record disposition, each departmental records manager shall sign and maintain
appropriate certificate of records documentation, which includes appropriate
cataloging information regarding the records being disposed.
(d)
The two broad
types of disposition available to university departments and offices are:
(i)
Record
destruction
(a)
The appropriate method of destruction is determined based upon the university
data within a record and the medium (i.e. electronic, paper) in which it
exists. These methods include, but are not limited to, shredding, recycling,
electronic deletion, and wastebasket disposal.
(b)
If restricted or
private data, as defined in the university's classification of rule
3349-9-18
of the Administrative Code is evident, records should be destroyed by shredding
or secure electronic destruction.
(c)
A department or
office's departmental records manager should complete and forward a certificate
of records destruction ("CRD") to the office of compliance and risk management
for review and signature before any records are destroyed. Transient records do
not require a CRD.
(d)
The office of compliance and risk management will
conditionally authorize the destruction of records (via the CRD) to ensure that
no records are disposed of prematurely or in violation of existing laws or
statutes.
(e)
University departments and offices are strongly
encouraged to conduct a records retention review and corresponding records
destruction annually.
(ii)
Record
transfer
(a)
Records of outgoing employees shall be transferred to their successors (or
designee, if no successor) and maintained in accordance with the NEOMED records
retention schedule.
(b)
Records with historical value may be transferred to the
respective departmental archive upon the completion and approval of the
certificate of records transfer (CRT) by the respective departmental records
manager.
(c)
If an employee has determined that records should be
transferred to a departmental archive, they should consult with their
departmental records manager for the appropriate procedures.
(d)
Records that are
transferred to the appropriate departmental archive become the administrative
responsibility of that departmental archive and shall reside permanently in
that departmental archive unless otherwise agreed upon.
(e)
In order to help
guarantee the preservation, integrity, and security of permanent records,
access to and inspection of such records housed in departmental archives,
whether by the general public or by university employees, shall be conducted
on-premise only.
(4)
Document imaging
and scanned documents
(a)
Paper-based records may be converted to an imaged
electronic record through document imaging (referred to as a "scanned
document") after consulting with the information technology
department.
(b)
As an electronic record, scanned documents are to be
managed in the same manner as records in other formats (i.e. paper, audiotape)
and in accordance with the NEOMED records retention schedule.