Record Retention, Disposal and Data Security Policy

Purpose

To maintain files for an appropriate period of time on all residents/fellows who were trained in an accredited residency/fellowship training program. This policy refers only to records that have a legal, operational or historic value.

Table 1: Office of Graduate Medical Education Responsibilities

Documents maintained, stored and destroyed by the Office of Graduate Medical Education. Programs may not store any of these documents listed in Table 1 with the exception of the Final Summative Evaluation.

GME File

Paper
Or
Electronic Format stored in electronic residence management systems, online benefit enrollment systems or on the encrypted network drive

Minimum Retention Period
Graduation Date or
Involuntary Termination Date

Resource
Benefit Elections Termination + 6 years ERISA (Employee Retirement Income Security Act)
Biographic Data (To include Social Security Number) Termination + 6 years NYS Retention and Disposition Schedule Ref # 90001
COBRA Election Notice and application (STD and FMLA) Effective date + 6 years ERISA (Employee Retirement Income Security Act)
Direct Deposit Forms Termination + 3 years NYS Retention and Disposition Schedule Ref # 90032
ECFMG Certificate Termination + 6 years NYS Retention and Disposition Schedule Ref # 90001

Employment Contract
Offer Letter
Wage Theft Forms

Termination + 6 years

NYS Retention and Disposition Schedule Ref # 90001
ERAS/Other System
Applicant data for underrepresented minority research
Publication Date + 3 Years HRP-072-SOP-IRB Records Retention
ERAS Application – matched candidates uploaded to Forms/Files in MedHub Termination + 6 years SUNY Record Retention and Disposition Schedule – Ref # 22303

Marriage Certificates
Birth Certificates

Termination + 6 years NYS Retention and Disposition Schedule Ref # 90001
Medical School Diploma Termination + 6 years NYS Retention and Disposition Schedule Ref # 90001
Moonlighting Permission

Termination + 6 years

NYS Retention and Disposition Schedule Ref # 90001

Passports, DS-2019, I-94, I-644 and any other visa documentation

Termination + 3 years NYS Retention and Disposition Schedule Ref # 90031
Primary Source Verification 5 years NYS Retention and Disposition Schedule Ref # 90001
Tax Withholding Certificates Termination + 4 years NYS Retention and Disposition Schedule Ref # 90016

Separate File

Paper
Or
Electronic Format stored in electronic residence management systems, online benefit enrollment systems or on the encrypted network drive

Minimum Retention Period
Graduation Date or
Involuntary Termination Date

Resource
Final Summative Evaluation Permanent ACGME Common Program Requirements V.A.2.a).(2).(a)
I-9 Form and supporting documentation Termination + 3 years NYS Retention and Disposition Schedule Ref # 90031
Leave of Absence/Family Medical Leave Records Termination + 6 years

NYS Retention and Disposition Schedule Ref # 90001

Malpractice records Permanent ACGME Expectations for Content of Resident and Fellow Files
Pre-employment drug testing, background investigation Termination + 7 years SUNY Records Retention and Disposition Schedule – Health Records Ref # 22235
USERRA Leave Records Termination + 6 years

NYS Retention and Disposition Schedule Ref # 90001

Verification of required certifications Termination + 6 years NYS Retention and Disposition Schedule Ref # 90001
Employee Health Patient Records

Termination + 7

SUNY Records Retention and Disposition Schedule – Health Records Ref # 22235
Employee Health Workers’ Compensation Claims

Termination +18 years

NYS Retention and Disposition Schedule Ref # 90015

Employee Health
Toxic and Bloodborne Pathogen Records

Termination + 40 years

NYS Retention and Disposition Schedule Ref # 90292

Table 2: Training Program Responsibilities

The training program is responsible for recording, maintaining, storing and destruction of the following documents as applicable.

File Accessible to Resident/ Fellow (Residency Management System/Encrypted Server)

Program File
Paper or Electronic
Minimum Retention Period Resource
Final Summative Evaluation

Permanent

ACGME Common Program Requirements V.A.2.a).(2).(a)
Low score reports Permanent ACGME Expectations for Content of Resident and Fellow Files
Records of the resident’s/fellow’s rotations, training experiences, and procedures, as applicable to the specialty Permanent ACGME Expectations for Content of Resident and Fellow Files
Training verification – start/end dates of training Permanent ACGME Expectations for Content of Resident and Fellow Files
Transfer Information
(Competency-based evaluations)
Permanent ACGME Expectations for Content of Resident and Fellow Files

Separate File – Proprietary to Program (Not to be shared with resident/fellow)

Paper or Electronic Minimum Retention Period Resource

ERAS Application

Unmatched Applicants
1 year + 1 day after match or final date of selection of candidates (e.g., application or interview for 2020 match – can be destroyed one day after the 2021 match)

SUNY Student Record Retention Schedule Ref # 22304

Interview documents

  • Interview evaluation form
  • Signed disclosure forms
    • 12-week rule
    • Policy review

Visa status attestations

Unmatched Applicants
1 year + 1 day after match or final date of selection of candidates
SUNY Student Record Retention Schedule Ref # 22304
  Matched Applicants
Termination + 6 years
SUNY Record Retention and Disposition Schedule Ref # 22303

As required in the Employment On-Boarding Policy:

  • ERAS Application to include:
    • Medical/Dental School Transcript (verified by Program Director)
    • Clinical Clerkship records
    • Documentation of prior Post-Graduate Experience, credentialing documentation (as applicable), and summative evaluation(s)

College Diploma/Transcript for MD Degree or equivalent (recommended)

Program responsibility to maintain while active in training.

 

GME Office responsibility to destroy termination
+ 6 years

SUNY Record Retention and Disposition Schedule Ref # 22303

Special Circumstances

The entire file should be kept for residents/fellows who do not complete the program or who are not recommended for board certification. In addition, in the event of a litigation hold, no files may be destroyed regardless of the disposal schedule until notification has been received that the case has been resolved.

Appointment of a Data Steward

Each training program should identify a staff member to serve as a Data Steward who will take responsibility for the storage, management and disposition of appropriate documentation related to training residents and fellows.

Record Disposal

In order to prevent a potential breach of protected or confidential information, it is recommended that the minimum retention period guidelines be followed for each type of document that is stored. This will greatly reduce UB’s vulnerability and liability in the event of a loss of information.

The preferred method of disposing of paper documentation is shredding. Do not recycle any documents containing sensitive or protected information.

Electronic deletion of data is more complicated. Hard drives/networks must be “sanitized”. This will require assistance and support from your Information Technology department. A simple “delete” process done at your workstation does not suffice to permanently delete electronic data. Be aware that backup copies of the data may also be stored and will need to be addressed. Program staff may not delete any electronic data from MedHub or alternate residency management systems.

Maintain a Record Disposal Document to record the date of disposal, description of the records identified and method of destruction. If sending paper records for shredding, a confirmation from the vendor is required that destruction of the records has been completed.

Handling Secure Data on Mobile Devices

Working offsite on mobile devices such as laptops, tablets and smart phones is commonplace. However, sensitive data may only be accessed on UB-approved mobile devices via secure VPN connection and within the remote desktop application. As a general rule, you are not permitted to download category 1 or category 2 data to your personal mobile devices.

Best Practices

  • Do not fax sensitive data. Most fax transmission lines are internet-based and are not hard-wired telephone lines and therefore, are not HIPAA-compliant;
  • If you are using a flash drive to transfer highly sensitive or confidential information, it must be encrypted; 
  • Encrypt all laptops that are used off site; 
  • Lock your workstation when you walk away from your desk; 
  • Keep documents containing sensitive information in locked drawers/ file cabinets; 
  • Power down your workstation at the end of the day; 
  • Delete data from your Downloads Folder on a frequent basis ( this can be set automatically in your computer's settings); 
  • Be aware or "shoulder surfers" who may be sitting behind or next to you and may be able to view sensitive data;
  • Formally review the information that is collected in your systems and who has access to it at least on an annual basis, more frequently, if possible. Make a note of the review in the event you are asked to provide documentation of the review; 
  • In addition to the UB policies listed below and this resource, familiarize yourself with data security procedures for your hospital or office location and steps to take in the event of a data breach.

Related Documents

Requests for Information

All requests for information prior to 1998 should go directly to the program director’s office or the hospital medical staff office.

Inquiries regarding your GME file or the UMRS/UDRS Health Plan

Requests for verification of training or malpractice coverage

All verification of training or malpractice coverage requests must be submitted electronically with a signed release. No requests are accepted by phone, fax or email.

University at Buffalo Foundation

  • Payroll verification (for credit card applications, mortgage applications, changing the number of tax deductions on W-4 forms, and amount being deducted from paycheck for incorrect insurance.
  • Direct deposit issues.

Residency Program Director’s Office

Contact your residency program director's office for:

  • Verification of procedure credentialing status.
  • Residency verifications which require information on the resident’s character, ability, clinical performance, etc.
  • Applications to the program – vacancies in program.

Training Verifications for Closed Programs

Contact the Federation of State Medical Boards for training verification in the following programs:

  • Family Medicine – Niagara Falls Memorial
  • Thoracic Surgery
  • Physical Rehabilitation and Medicine

Established:  2004
GMEC Approved Date: December 17, 2019