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Administrative Correspondence and Related Documents

Arranged By:   Chronological
Application Number:   89-26
Item Number:   170.01

Purpose

The correspondence provides documentation of general administrative and operational concerns of University Health Services and is exchanged primarily with other administrative and academic subdivisions of the University and outside public and private agencies and institutions or individuals providing or concerned with health care services. Related documents other than correspondence is contained within the series.  Paramount documents composing such materials are daily/monthly computer printouts showing internal reference statistics (in correlation with patient case files and charts), patient satisfaction survey data, Quality Assurance Studies, and original minutes from the Health Advisory Committee.  Also included within the series are original monthly and yearly statistical reports of referrals and service deliveries performed by University Health Services.

Procedure

Retain correspondence in office for three (3) years, then dispose of providing no litigation is pending or anticipated.  Retain related documents (statistical printouts, reports and minutes) in office for six (6) years, then dispose of (by shredding) if the documents contain data subject to patient confidentiality and provided no litigation is pending or anticipated.  Retain all materials remaining after the above disposals until screened by the University Archives staff for the possible accessioning of archival materials, then dispose of.

Allergy Name File

Arranged By:   Alphabetical and Chronological
Application Number:   89-26
Item Number:   170.02

Purpose

This is a card file serving as a summary/index to allergy cases handled by University Health Services.

Procedure

Retain in office until the lapse of six (6) years from the corresponding student's last date of contact with or treatment received from University Health Services, then dispose of providing all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Executed Consent Forms for Flu Shots

Arranged By:   Chronological
Application Number:   89-26
Item Number:   170.03

Purpose

These consent forms were executed by Health Services patients receiving flu shots in a flu prevention program spearheaded by Health Services in 1978.  The recommended retention period for these forms is based on providing for all litigation possibly emanating from such a flu shot program.

Procedure

Retain in office for twenty (20) years, then dispose of providing no litigation is pending or anticipated.

Lists of Active Faculty/Civil Service University Employees

Arranged By:   Chronological
Application Number:   89-26
Item Number:   170.04

Purpose

This computer printout listing is generated from the Personnel and Provost's Offices sources for keeping track of potential clientele from the University employee population.

Procedure

Retain in office for one (1) year, then dispose of.

Fiscal Administration Files

Arranged By:   Chronological by fiscal year
Application Number:   89-26
Item Number:   170.05

Purpose

This record series consists of fiscal administration files containing purchase orders, transfers of funds, internal work papers, travel vouchers and requests, receipts, deposits, invoice vouchers, supply requests, accounting ledgers, GAS reports, and copies of the budget (printout).  Originals are maintained with the University Offices of Purchasing, General Accounting and Accounts Receivable.

Procedure

Retain in office for three (3) years, then dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Grad Assistant Files

Arranged By:   Alphabetical and Chronological
Application Number:   89-26
Item Number:   170.06

Purpose

These files contain primarily copies of Graduate Assistantship Appointment forms and related internal documentation of Grad Assist activities.  The University's record copy Grad Assist files are maintained by the Graduate School and are scheduled for disposition accordingly.

Procedure

Retain in office for five (5) years following termination of assistantship, then dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

In-House Operational Policies and Procedures

Arranged By:   Chronological/Numerical
Application Number:   89-26
Item Number:   170.07

Purpose

In-House Operational Policies and Procedures

Procedure

Retain in office for six (6) years after superseded, then with the assistance of the University Archives staff, review the files and transfer any materials of archival value to the custody of the University Archives and dispose of the remaining documents after completion of the reviews and any archival accessions.

Lists of Referrals to "KCH" and Infirmary Patient Lists

Arranged By:   Chronological
Application Number:   89-26
Item Number:   170.08

Purpose

These lists were maintained in close conjunction with the later mentioned logs and registers.  ("KCH" referred to in the record series title above is in the abbreviation for the Kishwaukee Community Hospital).

Procedure

Dispose of accumulation provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Mental Health Clinic Patient Master Card File

Arranged By:   Alphabetical and Chronological
Application Number:   89-26
Item Number:   170.09

Purpose

This is a summary and cross-referencing card file of Mental Health Clinic patient case file data. Accordingly, a retention period identical to that recommended for the case files is recommended for this card file.

Procedure

Retain in office until the lapse of six (6) years from the most recent or last treatment rendered, then dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Patient Master Files

Arranged By:   Alphabetical
Application Number:   89-26
Item Number:   170.1

Purpose

This record series is maintained as case records of the medical/psychological history of individuals receiving treatment at the Health Center.  Documentation includes prescriptions; lab data; examination records; health statements; information from the patients' private physicians; parental consent forms (when applicable); accident/incident reports; consent forms for flu shots; and other diagnostic/treatment notes and charts.  These case files contain relevant pharmacy records, Mental Health Clinic records, and intake forms of the Allergy Clinic.  (With respect to the recommended disposition of this file series, the proposed retention period is in conformance with applicable records retention guidelines promulgated by the Illinois Medical Records Association.) This item supersedes State Records Application 89-26, item 170.10 to reduce the length of the retention period from twenty (20) years to ten (10) years.

Procedure

Retain in office until the lapse of ten (10) years from the last treatment rendered, then dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Patient Master File Cards

Arranged By:   Alphabetical and Numerical
Application Number:   89-26
Item Number:   170.11

Purpose

This is an overall index card file to the patient master files.  File reference and retrieved entries include name, address, social security number, date of birth, and a numerical cross reference to an existing chart.

Procedure

Retain in office until the lapse of twenty (20) years from the last treatment rendered, then dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Personnel Files

Arranged By:   Alphabetical by employee and by classification
Application Number:   89-26
Item Number:   170.12

Purpose

This record series consists of the civil service personnel files maintained by the Office of Health Services including resumes, copies of evaluations, raise sheets, non-status authorization changes, terminations, tuition waivers, and related correspondence.  Originals are maintained with the University's Office of Personnel Services (ref. Application 89-24, item #140.03).

Procedure

Retain in office for five (5) years after separation from employment, then dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Personnel Files

Arranged By:   Alphabetical
Application Number:   89-26
Item Number:   170.13

Purpose

This record series consists of the faculty personnel files including copies of licenses, appointment forms, vitae, copies of travel vouchers, vacation time/benefit reports, initial applications, and related correspondence (e.g. letters of inquiry).  Originals are maintained with the Office of the Provost.

Procedure

Retain in office for five (5) years after separation from employment, then dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Pharmacy Profiles

Arranged By:   Alphabetical and Chronological
Application Number:   89-26
Item Number:   170.14

Purpose

Pharmacy profiles were a card file and are now a computerized summary record of pharmaceutical holdings and prescriptions issued.  The recommended retention period for this record series meets all records retention requirements or guidelines set by the FDA and the Illinois Medical Records Association.

Procedure

Retain in office for five (5) years, then reuse and/or dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated. Computer tape/disc maintenance and preservation procedures are to be fully applied.

Prescription and Pharmacy Charge Slips

Arranged By:   Chronological
Application Number:   89-26
Item Number:   170.15

Purpose

Pharmaceutical prescription documentation is also maintained within the master patient case files. (The recommended retention period for this file is in conformance with all applicable and current FDA regulations).

Procedure

Retain in office for five (5) years, then dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Service Slips, Appointment Sheets, and Duty Schedules

Arranged By:   Chronological
Application Number:   89-26
Item Number:   170.16

Purpose

These records are generated and used internally for scheduling specific patient or client services.

Procedure

Retain duty schedules in office for six (6) years, then dispose of providing no litigation is pending or anticipated.  Retain all other record series documents in office for one (1) month, then dispose of.

Daily and Weekly Statistical Reports of Referrals and Service Deliveries

Arranged By:   Chronological
Application Number:   89-26
Item Number:   170.17

Purpose

These are original and draft copies of daily and weekly statistical reports of referrals and service deliveries performed by University Health Services.  The reports are used for short term reference and are ultimately summarized and/or incorporated within monthly and yearly statistical reports.

Procedure

Retain in office for one (1) year, then dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Monthly and Yearly Statistical Reports of Referrals and Service Deliveries

Arranged By:   Chronological
Application Number:   89-26
Item Number:   170.18

Purpose

These are duplicate and draft copies of monthly and yearly statistical reports of referrals and service deliveries performed by University Health Services.  The reports are structured by department within Health Services and are primarily referenced for budgeting purposes.  (Original monthly and yearly statistical reports are scheduled for disposition per item #170.01 of this application.).

Procedure

Retain in office for three (3) years, then dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Weekly Student Eligibility Reports

Arranged By:   Chronological
Application Number:   89-26
Item Number:   170.19

Purpose

These are printout computer runs received weekly from the Office of Registration and Records for tracking current eligible student enrollment.  The reports are used to monitor and plan services delivery capability of the clinic.

Procedure

Retain in office for one (1) semester, then dispose of.

Health Care Services Activities and Narcotics/ Pharmaceutical Supplies Registers and Logs

Arranged By:   Chronological
Application Number:   89-26
Item Number:   170.2

Purpose

This series contains the Emergency Room Logs, the Emergency Care Registers, the Trauma Clinic "Day" Register, the Outpatient Register, Mental Health Clinic Appointment Books, Infirmary Narcotic Counts, the Emergency Room Controlled Substance Logs, and the Lab Test Log.

Procedure

Retain in office for six (6) years after the last entry (in each respective log or register), then dispose of providing all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Specialist Referral Files

Arranged By:   Alphabetical by student
Application Number:   89-26
Item Number:   170.21

Purpose

This record series consists of the specialist referral files containing records of payments to physicians (specialists) for services rendered to students who were referred to them through the Health Services Office.  Information includes student’s name, social security number, name of specialist, date of payment, payment amount, the date the referral was returned to Health Services, and the date returned to the specialist.  Originals of this record series are maintained with the patient's chart.

Procedure

Retain in office for three (3) years, then dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Staff Time and Attendance Records and Request/Approval Leave Slips

Arranged By:   Chronological
Application Number:   89-26
Item Number:   170.22

Purpose

Employee time and attendance benefits are documented individually within staff personnel files also scheduled for retention under this records disposition application for an appropriately longer period than the one (1) year retention recommended for this item.

Procedure

Retain in office for one (1) year, then dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Student Index Cards

Arranged By:   Alphabetical/Chronological
Application Number:   89-26
Item Number:   170.23

Purpose

This is an overall card file index to case files created from students received and treated or assisted by University Health Services.

Procedure

Retain in office until the lapse of six (6) years from the corresponding students' last date of contact with or treatment received from University Health Services, then dispose of providing all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Student Insurance Files

Arranged By:   --
Application Number:   89-26
Item Number:   170.24

Purpose

The records contain documents used in the process of enrolling dependents in NIU's student insurance program and/or administering refunds.  Examples of records include copies of receipts, deposit tickets, listings of part-time students enrolled in the program, and printouts from General Accounting (e.g. listing of enrollees).

Procedure

Retain in office for two (2) years following supersedure and/or termination of coverage, then dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

X-Ray Films

Arranged By:   Chronological
Application Number:   89-26
Item Number:   170.25

Purpose

Results of x-ray readings are captured in a file series scheduled for disposition under a preceding item of this records disposal application (ref. item #170.10 of this application).

Procedure

Retain in office for five (5) years, then transmit to reclaimer for salvage providing no litigation is pending or anticipated.

Patient X-Ray Card File

Arranged By:   Alphabetical by patient
Application Number:   89-26
Item Number:   170.26

Purpose

This is an alphabetical card file indexing patient x-rays performed.  The recommended disposition of this series is in conformance with applicable records retention guidelines promulgated by the Illinois Medical Records Association.  Record series data are currently entered in the agency's computer system.

Procedure

Retain all record series formats in office for five (5) years, then dispose of provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

HIV Testing Records (Positive and Negative Results)

Arranged By:   Chronological by year/Numerical by file number
Application Number:   89-26
Item Number:   170.27

Purpose

This record series consists of documents which are used by the agency to test students for HIV at the University Health Service.  Contents include Consent for Anonymous HIV Antibody Blood Test (i.e., checklist statements, signature of counselor, date, client ID number); HIV Testing Survey (i.e., questions related to demographic information, sexual practices, substance use history, other risk factors, staff signatures, date, ID number); laboratory reports (i.e., place of testing, patient/hospital ID, age, sex, accession number, collection/report date, results); and Post Test Counseling-HIV Negative (i.e., code number or name, test results, test information, risk review, plan, signature of counselor, date). If the voluntary tests (positive and negative) possess a student name, then information is placed in the student's "Patient Master File" and retained for ten (10) years following last treatment date per item 170.10 of Application 89-26A.  If the test results are positive, then the information is also directed to the Illinois Department of Public Health via the Local Health Department.  (NIU informs the Local Health Department and the latter agency then contacts IDPH.)  IDPH permanently maintains Aids Adult Confidential Case Reports/Pediatric Confidential Case Reports per item 1 of Application 91-58 and confidential Report of HIV Infection per item 2 of Application 91-58.  For both positive and negative results, IDPH also maintains HIV Counseling/Testing Records and Sero-Prevalence Blood Test Results for ten (10) years per items 4 and 6 of Application 91-58.  However, NIU forwards only positive HIV Test Reports to IDPH. Local Health Departments maintain AIDS Case Files for twenty-five (25) years and AIDS Confidential Reports (HIV Counseling/Testing Records - identified by number only) for five (5) years pursuant to records retention schedules approved by the Local Records Commission.  (This series has no value to the university other than as documentation of its sexually transmissible disease testing and reporting procedures and activity.)

Procedure

Retain in office for five (5) years, then dispose of (by shredding) provided all audits have been completed under the supervision of the Auditor General, if necessary, and no litigation is pending or anticipated.

Contact Us

Ethics and Compliance Office
Health Services Building, 2nd floor
815-753-5560
eco@niu.edu