• Patient and resident entertainment records 

• Art collection records 

• Therapeutic recreation records 

• Music therapy records 

• Baycrest museum records 

• OCAD partnership records 

• Art administration 

• Education Planning Committee 

• Quarterly reports 

• Office of Academic Education records 

• Conference administration records 

• College/university affiliation agreements 

• Library services records 

• Education seminars and lectures 

• Annual general meeting records 

• Board meeting records 

• Board committee records 

• Academic Advisory 

• Clinical Strategy, Quality and Safety 

• Finance and Audit 

• Fiscal Advisory 

• Governance 

• Government Relations 

• Investment 

• Management Resources and Compensation 

• Medical Advisory 

• Strategic Planning 

• Annual reports 

• Executive team records 

• Corporate and medical staff bylaws 

• Letters patent 

• Board policies 

• Insurance and claims records 

• Legal opinions 

• Government funding agreements 

• Contracts 

• Operating licences 

• Deeds 

• Budgets 

• Payroll information 

• Expense reports 

• Annual financial statements 

• General ledger 

• Books of account and accounting records 

• Billing invoices 

• Budget analysis records 

• Accounts payable reports 

• Invoices 

• Receipts 

• Retail sales tax records 

• Employee orientation materials 

• Special event records 

• Workplace Safety and Inspection Board (WSIB) case management reports 

• Febrile respiratory illness screening, tracking and communication 

• Ministry of Labour and Public Health correspondence and orders 

• Safety group plans and supporting materials 

• Occupational Health and Safety project and program files 

• Job classification compensation files 

• Vacancy recruitment/selection material 

• Employee issues/relations files 

• Equipment and software licenses, contracts 

• Customer support tracking 

• Vendor contact information 

• Freedom of information and privacy records 

• Purchasing and procurement records 

• Receiving records 

• Competitive bidding records 

• Purchasing contracts 

• Product evaluation and trials 

• Courier records 

• Inventories 

• Ombudsperson case files 

• Terms of reference 

• Evaluation guidelines 

• “Speak Your Mind” concerns, compliments, suggestions 

• eNewsletter database 

• Baycrest publications 

• Corporate photo archives 

• Communication plans 

• Press releases 

• Grievance/arbitration files 

• Workplace investigation files 

• Organizational change files 

• Pay equity plan and supporting materials 

• Labour relations issues/policy files 

• HR project and program files 

• Employee benefit and insurance documentation 

• Annual financial audit documentation 

• Job postings 

• Tuition assistance records 

• Strategic planning documentation 

• Training records 

• Food and Nutrition Services records 

• Retail food reports 

• Toronto Public Health reports 

• Menus 

• Surveillance videos 

• Redevelopment and emergency management records 

• Facilities and environmental services records 

• Construction and renovation records 

• Mail and receiving records 

• Gift Shop and Terraces of Baycrest convenience store records 

• Paging activity records 

• Operating plan processes 

• Research institute account records 

• Government funding submissions 

• Volunteer Youth Council minutes

• Volunteer Department reports

• Jewish Home for the Aged interprofessional committee

• • Volunteer engagement surveys

• Training centre records

• Administration records

• Research Ethics Board administration files

• • Clinical trial records

• Client health records

• Medical staff credentialing records

• Medical administration records

• Infection Control meeting records

• Patient safety indicators reports

• Outbreak audits and control measures

• Hand hygiene audits

• Safety event reporting system records

• Patient appointment schedules

• Staff scheduling

• Quality indicator reports

• Census reports

• Safety walkabout reports

• Patient registration information

• Nursing assignment sheets

• Patient transfer/discharge records

• Communication books

• Patient satisfaction survey information

• Clinical ethics records

• Clinic records

• Program administrative records

• Risk monitoring

• Psychiatry records

• Project records

• Pastoral services records 

• Baycrest drug formulary 

• Hazardous medication training records 

• Summary of drug inventory 

• Narcotic and controlled drug records 

• Pharmacy administration records 

• Diagnostic Imaging quality assurance reports 

• Radiologist registrations

• Physiotherapy quality documentation 

• Staff education requisitions 

• Documentation audits 

• Social Work administrative records 

• Audiology administrative records 

• Speech language pathology administrative records and assessments 

• Investigations

• Reports and audits

• 24-hour monitoring reports

• Care plans

• Apotex meeting records

• Residents’ Advisory Council records

• Family Advisory Council records

• Ministry of Health and Long-Term Care inspection reports

• Fitness procedures records

• Occupancy records

• Grant applications

• Toronto Housing allowances

• Client apartment safety inspection records

• Client satisfaction information

• Therapeutic recreation program records

• Toronto Public Health inspections and audits

• Parking assignments

• Monthly newspapers

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 and disposal: One year after last use

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 and disposal: One year after last use

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 and disposal: Seven years

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 and disposal: Three years after creation date for general employment records, 40 years for occupational health and safety, and workplace safety and insurance records

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 and disposal: Until follow-up complete plus two years

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 and disposal: One year after date of last use

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 and disposal: 10 years after discharge or death

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 and disposal: One year after date of last use

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 and disposal: 10 years after discharge or death

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 and disposal: 10 years after discharge or death

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 and disposal: Seven years after superseded or, as applicable, after appeal rights expire

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 and disposal: Seven years after superseded

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 and disposal: Three years

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 and disposal: Five years after day on which the image is created.

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 and disposal: 10 years after discharge or death

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 and disposal: 10 years after discharge or death

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 and disposal: Two years

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 and disposal: Three years after creation date

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 and disposal: Three years after creation date for general employment records

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 and disposal: Three years after creation date for general employment records, 40 years for occupational health and safety, and workplace safety and insurance 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 and disposal: One year after date of last use

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 and disposal: Seven years

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 and disposal:  40 years

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 and disposal: Two years from the date of file closure, or, if serious, until finally resolved by settlement, judgment expiry of appeal period

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 and disposal: One year after last use

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 and disposal: Until follow-up complete plus two years

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 and disposal: 25 years

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 and deidentified research participants (Baycrest staff, research staff, students, Baycrest patients, members of the community)

Retention and disposal: 25 years

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 and disposal: 25 years

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 and disposal: One year after date of last use

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 and disposal: Seven years

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 and disposal: Two years

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 and disposal: Seven years from last day of person’s residency

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 and disposal: Seven years from last date of residency

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 and disposal: One year after date of last use