Atikokan General Hospital

Public Reporting

Directory of Records

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To assist in document classification, the following scope notes describe not only what is included, but also what is excluded from each subject group.

Table of Contents

  1. Administration
  2. Building Maintenance / Operations / Development
  3. Finance
  4. Human Resources
  5. Legal
  6. Management / Policy
  7. Public Relations / Communications
  8. Research / Planning

 


Administration

A00 Administration – General
Includes administrative records which cannot be classified elsewhere. Use only if no other heading is available.

A01 Associations / Organizations
Includes correspondence, minutes, agendas, notices and reports regarding organizations, associations and unions to which staff or Board members belong or with which they communicate in the course of their duties, such as the Ontario Hospital Association.

INCLUDES: CAW, CHA, HSCN, other hospitals, ICES, ONA, and PAIRO.

EXCLUDES: staff development conferences – see H20. Negotiations with unions – see negotiations, H15

A02 AGH Departments / Services
Includes folders for each hospital department and/or service i.e. Lab Department or Volunteer Services

A03 Computer / Information Systems
Includes records regarding all types of information systems in use. Includes information on system design and implementation, office automation, and program listings. Also includes computer maintenance records, flow charts, file layouts and requests for modification and upgrades.

INLUDES: inventories of network equipment and user I.D.s; hardware and software designations, master system descriptors, and summaries

EXCLUDES: Reports – file by subject or in Research R06

  • back up tapes – identify by subject
  • maintenance contracts – see contracts and agreements – L01
  • Hardware – see office equipment – A05

A04 Inventory Control
Includes all records regarding the management of inventories such as stock adjustments, inventory cards, stockroom invoices, confirmation slips for rush orders and packing slips. Also includes Audio/Visual inventories.

A05 Office Equipment
Includes records and manuals regarding the design and features of office equipment and furniture. Includes such equipment as copiers and fax machines. Specific records include service and maintenance records, long distance phone call reports, telephone request reports, trouble logs and special orders.

EXCLUDES: phone bills – see accounts payable. F01

A06 Conferences – External
Includes invitations, approvals, agenda, registrations, notes on the proceedings, and other records regarding external conferences and seminars attended by staff.

EXCLUDES: associations/organizations – see A01 and conferences sponsored by staff development see H20.

A07 Records Management
Includes information regarding the hospital’s management of records, regardless of medium. Specific records include file lists, retention schedules, and related correspondence.

EXCLUDES: Records disposition – see A08.

A08 Records Disposition
Includes records regarding the disposition of all records belonging to the Board. Includes lists of destroyed records and records in storage, lists of transferred records and forms authorizing the destruction of records.

A09 Intergovernmental Relations
Includes correspondence and reports between the hospital and various governmental offices such as the Ministry of Health and Long Term Care.

Includes Underserviced Area Program, JPPC, and correspondence from government ministries other than the MOHLTC.

A10 Uniforms
Includes orders and other records regarding uniforms used by hospital staff and paid by the hospital.

A11 Charities
Includes records regarding the filing of charitable organization returns.

A12 Vendors / Suppliers / Caterers
Includes records regarding vendors and suppliers of goods and services as well as information about these goods and services such as catalogues, price lists, and correspondence.

A13 Consultants – External
Includes records relating to the selection, appointment and monitoring of consultants such as engineers or architects. Includes correspondence, proposals, resumes and company profiles.

Excludes – Reports of Consultants – file b subject
Quotations/Tenders – see F14

A14 Duplicating / Printing Services
Includes requests and memos regarding the printing of hospital documents, publications, and forms. Also includes printing logs.

A15 Mail Services – External
Includes records regarding dealings with the hospital’s mailroom, Canada Post, and courier companies. Also includes general information on mail and courier services.

A16 Lobbying
Correspondence relating to petitions for hospital funding and financial support.

A17 Forms
Includes records regarding the creation, revision and management of forms. Also includes examples of blank copies of forms, form masters, printing requests, specifications, records usage and cost history.

Excludes – all completed forms – file by subject.

 

Building Maintenance / Operations / Development

B00 Building Maintenance / Operations / Development – General
Includes building maintenance/operations/development records which cannot be classified elsewhere. Use only if no other heading is available.

B01 Accommodation Planning
Includes records regarding the allocation of workspace to staff. Includes planning of the effects of admission statistics, projected workspace needs and space utilization, the planning of the functional space and the planning of the physical layout of the space.

B02 Security
Includes records regarding the security of office and hospital building facilities and properties such as control of keys, trespassing etc.

B03 Health and Safety
Includes records regarding the occupational health and safety of staff and patients. Includes Workplace Hazardous Materials Information System, material safety data sheets, fire drills and alarm tests, safety requests, fire safety plans and bomb threat issues. Also includes quarantines, infections and infestations.

Excludes – Accident Reports – see L09
Claims – See L04

B04 Vehicles
Includes records of all vehicles currently owned, operated and maintained by the hospital. This includes vehicle history files, vehicle maintenance, registration and disposal.

B05 Operational Equipment
Includes maintenance and other records of operational equipment used by staff members, such as lawnmowers, scrubbing machines, snowblowers, steam cleaners and vacuums.

B06 Maintenance
Includes maintenance requisitions, work orders, and all other records detailing the preventive maintenance of hospital properties and buildings.

B07 Specifications
Includes technical specifications for a project or property, e.g. mechanical, electrical, and structural. Includes building and fire code requirements and architect’s instructions.

B08 Capital Building Projects
Includes estimates, progress reports, certificates of clearance, project drawings, and correspondence regarding the building of hospital facilities and other properties under capital funds.

B09 Permanent Improvements
Includes project records and supporting documentation specific to additions, renovations, and alterations to the hospital.

Excludes – Budget Material – see Budgets – F04; Construction Tenders – see Tenders/Quotations – F14

B10 Site Surveys
Includes land survey information such as legal property surveys, construction layout and control surveys, and field notes. Also includes soil boring reports.

B11 Building Approvals
Includes documentation pertaining to the approval of building plans by the Municipality, Fire Marshal’s Office, Ministry of Health and Long Term Care and other government bodies, such as site plan approvals, building permits, and municipal reports.

B12 Operations
Includes records of the operations of buildings, such as environmental matters, grounds-keeping, energy management, heating, ventilation, air conditioning, pool operations, pest control, snow clearance, and cleaning.

Excludes – Health and Safety – see B03

 

Finance

F00 Finance – General
Includes records regarding finance which cannot be classified elsewhere Use only if no other heading is available.

F01 Accounts Payable
Includes records documenting funds payable by the Board, such as legal fees, vendor transaction listings, payment vouchers, gas, hydro and phone bills.

F02 Audits
Includes records regarding internal and external financial audits of records.

Excludes – Audited Financial Statements – see Financial Statements – F06

F03 Banking
Includes records regarding banking transactions and relationships with banks. Includes bank statements, bank reconciliations, deposit books, cancelled cheques, cheque stubs and money order rates.

F04 Budgets
Includes departmental and hospital-wide budgets, both capital and operating. Includes all working notes, budget formula, calculations, current estimate highlights, preliminary formula budget, calculation sheet summaries, and budgeted vs actual reports.

F05 Fundraising
Includes correspondence with the hospital Foundation and its Board.

Excludes Bequests – see F16

F06 Financial Statements
Includes audited financial statements and year end reconciliation reports.

F07 Grants / Subsidies
Includes records pertaining to all grant programs
Excludes Agreements – see L02.

F08 Journal Vouchers
Includes completed journal voucher forms, input forms, and all background documentation used to substantiate journal entries.

F09 General Ledger
Includes all records in the books of original entry, whether maintained in book format or as a computer report.

F10 Subsidiary Ledgers, Registers and Journals
Includes all subsidiary ledgers, registers and journals such as Payment and Receipt Journals and Payroll Registers, and Purchase Order Registers. Also includes year-end adjustments.

F11 Payroll
Includes all records of payments of salary, wages and deductions to employees. Includes payroll master records (PMRs), time cards, direct deposit request forms, payroll update logs, hold-backs, and payroll deduction and billing reports.

F12 Purchase Orders
Includes purchase orders and blanket orders authorizing the procurement of goods and services.

Excludes Tenders/Quotations – see F14
Excludes Purchase Order Registers – see Subsidiary Ledgers – F10

F13 Purchase Requisitions
Includes purchase requisitions received from departments for capital planning, copies retained by departments for follow-up, and related correspondence.

Excludes Tenders/Quotations – see F14

F14 Tenders / Quotations
Includes records regarding quotations and tenders obtained from suppliers of goods and services, such as office supplies, construction and pest control. Includes Requests for Proposal, Request for Quotations, Specifications, Invitations to Tender, Proposals, Tender Submissions, bid and performance bonds, and all documentation regarding the selection process.

Excludes – Vendors/Suppliers/Caterers – see A12
Excludes – actual contracts – see “L”

F15 Accounts Receivable
Includes records documenting accounts owed to the hospital including patient billings for ambulance use, ECW/CCC patient charges, out of province/nonresident billings, billings to the MOHLTC for diagnostic services, semi-private billings to insurance companies, CCAC, Meals on Wheels Dietary Recovery, Self Charges out of ER, MDS Lab, and billings to locum physicians for accommodation.

F16 Bequests
Includes records regarding the background information and copies of wills regarding the administration of bequests.

F17 Taxation
Includes records documenting taxation such as Charity Returns, GST Refunds, Ontario Retail Sales Tax.

F18 Petty Cash
Includes records relating to the office petty cash accounts. Includes disbursements and memos.

F19 Capital Projects Financing
Includes records relating to the financing of capital projects. Includes quarterly reports, working papers, building monthly costs, capital payment vouchers, approvals, costing and correspondence with architects and contractors.

Excludes – Final Cost Statements – see Financial Statements – F06

F20 Financial Working Papers
Includes all drafts, calculations and other working papers associated with the development of financial statements for the Board of Directors.

F21 Deprecation
Includes depreciation on major equipment, information technology purchases and software.

F22 Investments
Includes records regarding the hospital’s investments, term deposits and promissory notes.

 

Human Resources

H00 Human Resources – General
Includes records regarding Personnel matters which cannot be classified elsewhere. Use only if no other heading is available.

H01 Employee Records
Includes employee records, such as letters of agreement and offer, initial resume, application for employment, internal applications, correspondence relating to seniority (except the related work forms – see Payroll Dept records), performance appraisals, letters of recognition, probationary interviews, skills checklists, college certificates, training and certification, requests and confirmations of education leave, orientation skills checklists, permission to complete reference checks, completed reference checks, job descriptions, transcripts, diplomas, notice of resignation, notices of possible disciplinary actions, disciplinary actions, notice of termination, criminal reference checks, modified work agreements, WSIB correspondence, driver record searches.

Includes records for Board members – for their initial resume and to track their training/conference attendance records and years of service on the Board.

Note: Employee records are kept in 3 places:

  • CEO’s office for the above noted correspondence
  • Payroll Department for all pay related records, income tax information, etc.
  • The employee health records and kept in the office of the AED-Patient Care Services (Employee Health Nurse)

Personnel records in the CEO’s office are arranged in the following sections:

  1. Seniority
    All correspondence regarding seniority goes on the personnel file in the CEO’s office. Payroll tracking forms go into payroll department records.
    • Seniority standings
    • Requests for changes in status: full time < > part time
    • Requests for changes in hours
    • Notices of pay increases
    • Maternity / Paternity leaves
    • Other leaves of absence i.e. vacations, paid leaves, except educational leaves (see under Re-Cert/Added Education…)
       
  2. Performance Appraisals
    • Performance appraisal forms
    • Letters of recognition
    • Probationary interviews
    • Skills checklists as part of the nursing orientation/performance appraisal
    • Employee completed “Task Appraisal” forms
       
  3. Re-Certifications / Added Education, Skills
    • Proof of registration in appropriate college
    • Re-certifications
    • Added skills
    • Extra education, courses or seminars attended
    • Training, certification (e.g. defibrillation)
    • “Futures” training
    • Requests / confirmations for educational leaves
       
  4. Orientation
    • Orientation checklist
    • Skills checklist (some of these may be found in the Performance Appraisal section, depending on how they were presented)
    • Orientation to job role - signed job description
    • Orientation to Privacy Responsibility - signed agreements
       
  5. Recruitment and Selection
    • Letters of application / Application forms
    • Resumes
    • References
    • Permission to complete reference checks (but completed reference checks go on job competition file – H10)
    • Correspondence with other institutions re: start and completion of training, etc.
    • Letter of Offer
    • Acceptance of Offer
    • Employment Agreements
    • Educational qualifications – school transcripts, copies of diplomas and / or degrees
    • Notices of resignation
    • Exit Interview
       
  6. Discipline
    • Grievances: complaints by / against employee
    • Notices of possible disciplinary actions
    • Disciplinary actions
    • Notice of termination
       
  7. Miscellaneous
    • Extraordinary circumstances – summons
    • Income tax information/payroll deductions (oddities)
    • Letters to other institutions
    • Police checks
    • Driver record searches
    • WSIB
    • Modified Work Agreements

H02 Attendance
Includes records regarding employee attendance, absences and hours of work, employee service awards, seniority lists and sick time reports.

H03 Benefits
Includes brochures, rates, quotes, correspondence and explanatory documents regarding benefits offered to employees such as group insurance, dental plans, Employee Assistance Program, benefit rate changes, premium adjustments i.e. Clarica, Claim Secure, Stevenson and Hunt and WSIB.

H04 Human Resources Planning
Includes records succession planning and retirement, staff turnover rates, staff mobility and related records.

H05 Job Descriptions
Includes key tasks, job descriptions and specifications as well as background information used in their preparation or amendment.  A printout of each current job description followed by the Physical Demands Analysis for that job is kept in the business office in one main binder.

Note: Signed job descriptions are filed on the personnel record (see H01).

H06 Collective Agreement Administration
Includes records regarding the administration and interpretation of the hospital’s collective agreements. Includes implementation plans and related records for ONA and CAW collective agreements.

Excludes Grievances – see H14
Excludes Collective Agreements – see L02
Excludes Negotiations – see H15

H07 not used yet

H08 Salary Administration
Includes records regarding the planning and scheduling of salaries, such as job evaluations, job classification systems, salary surveys and schedules. Also includes any reference material retained regarding issues related to pay equity.

H09 Pension
Includes contribution cards detailing pension and benefits obligations due to retired employees under HOOPP. Also includes general information on HOOPP and annual reports. Includes payroll records required to determine and verify pension payments.

Excludes Deductions – see Payroll, - F11.

H10 Recruitment
Includes records regarding the recruitment of staff. Includes job postings, copies of advertisements, records regarding competitions, applications and resumes. Categories may include internal and external ads. Correspondence under this heading will include job competition correspondence including all materials related to the interview process.

H11 Bursary / Scholarship
Includes records pertaining to the administration of the hospital bursary for high school students.

H12 Leaves of Absence
Includes records regarding employee entitlements, leaves, such as requests, planners and correspondence.

Excludes Attendance – see H02
Excludes Vacations – see H18

H13 Employment Equity
Includes records regarding affirmative action such as workshop packages, questionnaires and plans, strategies, correspondence with affirmative action representatives and reports.

H14 Grievances
Includes records regarding grievances filed by employees such as evaluation reports, notifications, correspondence with union concerning grievance initiators and legal opinions.

H15 Negotiations
Includes related correspondence, records regarding collective bargaining with the CAW and ONA unions. Includes final offers, memoranda of settlement, mediations, arbitrations, and materials used in preparation for bargaining.

H16 Staff Allocation
Includes records concerning the allocation of staff within the system.

H17 Students
Includes applications for student placements, preceptorships, etc. Does not include recruitment of summer students (H10) or contracts with educational institutions (L02)

H18 Vacations
Includes records regarding employee vacations. Records include requests, schedules/planners and correspondence.

H19

H20 Staff Development
Includes records regarding courses and conferences facilitated by the hospital for staff development and information on career and professional development programs. Also includes orientation materials and staff development calendars. These records would likely be a simple listing of staff participating in a particular workshop or conference.

 

Legal

L00 Legal – General
Includes records regarding legal affairs which cannot be classified elsewhere. Use only if no other heading is available.

L01 Legal Advice – Confidential
Includes records of lawsuits and legal advice given.

L02 Contracts and Agreements
Includes contracts and agreements of all kinds i.e. for equipment rental, vehicle lease, union collective agreements, land purchase agreements, Agreements with the MOHLTC.

L03 Insurance
Includes records regarding the hospital’s insurance liabilities such as agents and adjusters’ premiums, policies, certificates and appraisals.

Excludes – Insurance Claims – see L04
Excludes – Accident reports – see L09

L04 Claims
Includes all liability claims made by employees and other parties against the hospital or by the hospital against other parties.

L05 Property Appraisals
Includes property appraisals, valuations, and quotes concerning land owned by the hospital or under consideration for purchase. Also includes backup documentation and related correspondence.

L06 Permits / Facility Bookings
Includes correspondence relating to the booking of conference rooms, or other hospital facilities for purposes such as training, polling stations or community events.

L07 Acts / Regulations
Includes single copies of Acts and Regulations relevant to the hospital’s activities, as well as correspondence and discussion papers concerning the Acts and Regulations and amendments to them.

L08 Deeds
Includes original deeds to any hospital owned property.

L09 Accident Reports
Includes reports of staff incidents/accidents or patient/resident/visitor incidents/accidents.

L10 Property Damage Reports
Includes reports and general correspondence regarding property damage, theft or loss. Also includes vandalism, weather related damage etc. and copies of repair invoices.

L11 Police Matters
Includes correspondence between the hospital and police department regarding extra duty officers, calls for assistance with patients or security for disaster plan and related items.

 

Management / Policy

M00 Management / Policy – General
Includes Management/Policy records which cannot be classified elsewhere. Use only if no other heading is available.

M01 By-Laws
Includes final versions of the hospital’s, the medical staff and the foundation by-laws, amendments and special resolutions and attachments that are legally part of the by-laws.

M02 not used yet

M03 not used yet

M04 Policies / Procedures
Includes proposed and approved policy and procedure manuals, guidelines, and directives and all other policies and procedures established by the hospital general administration and by its individual departments.

M05 Hospital Reports
Includes hospital analysis reports, unusual occurrence reports and reports to the Board by senior management.

M06 Board Committees
Includes agendas and minutes of all Board and hospital committees.

M07 not used yet

M08 Board of Directors
Includes correspondence pertaining to the recruitment of board members, board profiles including years of service and election information. Also includes information on governance resources, and training opportunities.

M09 not used yet

M10 Organization
Includes records regarding reporting relationships, organization, organizational analysis etc. Also includes organizational charts.

 

Public Relations / Communications

P00 Public Relations / Communications – General
Includes records regarding communications/public relations which cannot be classified elsewhere. Use this heading only if no other subject heading is available.

P01 Media Relations / News Releases
Includes records regarding hospital relations with the various media. Includes press releases and information releases.

P02 Speeches
Includes master copies or duplicates of speeches prepared for delivery by Board members, hospital staff and elected officials. Also includes presentations.

P03 Conctact / Mailing Lists
Includes all lists of individuals or organizations to whom hospital communications are sent for information purposes.

P04 Publications
Includes records and artwork regarding publications currently being produced by the hospital such as brochures, handbooks, strategic plans etc.

P05 Newsclippings
Includes clippings of news items from newspapers, magazines and other publications in Canada and worldwide regarding the hospital, healthcare issues, Board and staff members.

P06 Events
Includes correspondence pertinent to events sponsored by the hospital. Includes mission week activities and brochures, retirements, and socials.

Excludes recruitment events – see M06 Health Professionals Recruitment and Retention Committee

P07 Advertising
Includes correspondence, copies of advertisements, ad books and price lists.

Excludes recruitment – see H10

P08 Complaints and Commendations
Includes complaints and commendations received from clients and the general public regarding various programs and services provided by the hospital and its staff.

P09 Photographs
Includes photos of board members and hospital staff, photos of hospital facilities and equipment.

 

Research / Planning

R00 Research / Planning – General
Includes general research/planning records which cannot be classified elsewhere. Use only if no other subject heading is available.

R01 not used yet

R02 Strategic Planning
Includes all strategic planning and operational planning documents, mandates as well as related correspondence, background and reference information.

R03 not used yet

R04 not used yet

R05 Disaster Planning
Includes records regarding planning and development of emergency plans as well as information pertaining to practice sessions for the various emergency codes including mock disaster exercises.

R06 External Research
Includes publications received on various research projects done on healthcare issues. Also includes “Hospital Report” documents and Survey requests.

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