RECORD RETENTION POLICY AND PROCEDURES

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					                                                                                           Baptist Healthcare System, Inc.
                                                                                                  Record Retention Policy

                                                                                Category          Effective Date          Revised

                                                                                 Legal               9/1/99

                                                                                 Index                Page

                                                                                                     1 of 66



                                          RECORD RETENTION
                                        POLICY AND PROCEDURES
SUBJECT:                                 DOCUMENT AND RECORD RETENTION GUIDELINES

SCOPE:                                   All BHS Facilities and Departments

AUTHORIZATION:                           Baptist Healthcare System, Inc.
                                         Tommy J. Smith, President & CEO

PURPOSE:
To provide minimum retention periods for documents and records maintained by Baptist
Healthcare System, Inc. (BHS).

POLICY:
All employees and agents of BHS are responsible for ensuring that all records are maintained,
preserved, and destroyed in accordance with all applicable laws and regulations and this Record
Retention Policy. All records generated and received by BHS are the property of BHS. No
employee of BHS, by virtue of his or her position, has any personal or property right to such
records even though he or she may have developed or compiled them. The unauthorized
destruction, removal or use of such records is prohibited. No one may falsify or inappropriately
alter information in any record or document. Information pertaining to unauthorized destruction,
removal or use of BHS records or regarding falsifying or inappropriately altering information in
a record or document should be reported to BHS management, either directly or through the
Compliance Line (1-800-783-2318).

The attached chart contains minimum retention periods for records to be maintained by BHS.
Where there is no statutory or regulatory requirement, BHS hospitals may choose to change the
retention period upon their discretion. The retention periods are based on complying with
statutory and/or regulatory requirements, meeting industry or accreditation standards and/or for
litigation purposes. While it is intended that all records of BHS will be maintained in accordance

ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management
Association, CAP=College of American Pathologists, CFR = Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative
Regulations, KRS = Kentucky Revised Statutes

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                                                                    Baptist Healthcare System, Inc.
                                                                            Record Retention Policy
with the minimum retention periods set forth in this policy, it shall not be construed to be
negligence if such records are not maintained in accordance with this policy. All records listed
and/or records substantially similar to those listed, must be maintained in a retrievable form for
the period listed. Retrievable form may include paper copies, microfilm, microfiche, magnetic
tape, diskette, CD or arrangements may be made to have the records electronically maintained.
The records must be retrievable and reproducible throughout the minimum retention period.

The record retention periods will be revised and updated as needed to ensure regulatory
compliance and to reflect changes in guidelines. This Record Retention Policy and all revisions
will be included and distributed as part of the BHS Legal Manual and shall be included as a
protocol under the BHS Corporate Responsibility Program.

Records that have satisfied their required period of retention may be destroyed in an appropriate
manner.

PROCEDURE:
1.  Each hospital and/or department will designate one or more individuals to oversee the
    retention of records. Such individual(s) will familiarize themselves with this policy and
    the attached chart of retention periods.

2.        Upon determination that certain records’ retention period has expired, such designated
          person(s) may authorize the destruction of the records.

3.        Records that cannot be destroyed include records with permanent retention periods and
          records pertaining to matters in litigation. In the event of a lawsuit or government
          investigation, the applicable records that are not permanent cannot be destroyed until the
          lawsuit or investigation has been concluded.

4.        Records must be destroyed by an appropriate method. Appropriate methods for
          destroying paper include burning, shredding, pulping, and pulverizing. Methods for
          destroying microfilm or microfiche include recycling and pulverizing. Electronic data
          may be destroyed by overwriting data or reformatting disks (deleting a file is not total
          destruction).

5.        A record of destruction must be maintained indicating the types of records destroyed,
          inclusive dates covered, the date of destruction, method of destruction and signature(s) of
          individual(s) supervising and/or witnessing the destruction. Such record of destruction
          shall be kept permanently and contain a statement that the records were destroyed in the
          normal course of business.


ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management
Association, CAP=College of American Pathologists, CFR = Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative
Regulations, KRS = Kentucky Revised Statutes

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                                                                            Record Retention Policy
6.        If an employee believes another employee, a contractor or other individual is
          impermissibly destroying records or otherwise violating this policy, he/she should contact
          his/her supervisor or another member of management at the facility. If an employee is
          uncomfortable seeking resolution in such a manner, he/she may contact the Compliance
          Line (1-800-783-2318).

Approved:

_________________________
Tommy J. Smith

Date:_____________________




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management
Association, CAP=College of American Pathologists, CFR = Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative
Regulations, KRS = Kentucky Revised Statutes

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ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management
Association, CAP=College of American Pathologists, CFR = Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative
Regulations, KRS = Kentucky Revised Statutes

                                                          Page 4 of 66
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                                                                                                                                                                 Record Retention Policy


                                                             BAPTST HEALTHCARE SYSTEM
                                                              RECORD RETENTION POLICY

                                                                         TABLE OF CONTENTS



                                                                            Hospital Medical Records

          Ambulance Service Records ..............................................................................................................1

          Cardiology..........................................................................................................................................1

          Chemical Dependency .......................................................................................................................1

          Death Records....................................................................................................................................2

          Department Logs / Records ...............................................................................................................2

          Diagnostic Images..............................................................................................................................3-4

          Disease Index .....................................................................................................................................4


ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                           Page 5 of 66
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                                                                                                                                                           Record Retention Policy
          Equipment Records............................................................................................................................4

          Labs – Clinical ...................................................................................................................................5-8

          Mammography...................................................................................................................................8

          Master Patient Index ..........................................................................................................................9

          Medical Device Reporting .................................................................................................................9

          Medical Records ................................................................................................................................9

          Nuclear Medicine...............................................................................................................................9

          Obstetrics and Gynecology ................................................................................................................10

          Operative Index..................................................................................................................................10

          Patient Complaints .............................................................................................................................10

          Pharmacy............................................................................................................................................10–12

          Sterilization / Autoclave Records ......................................................................................................12

          Surgery Register / Log .......................................................................................................................12




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                         Page 6 of 66
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Home Health

          Clinical Records.................................................................................................................................13



                                                                    Hospital / Administrative Records

          Accreditation......................................................................................................................................14

          Contracts ............................................................................................................................................14

          Dietary................................................................................................................................................14-15

          Education ...........................................................................................................................................15-16

          Employee Medical Records ...............................................................................................................16

          Engineering ........................................................................................................................................16-18

          Housekeeping.....................................................................................................................................18

          Incident Reports .................................................................................................................................19

          Infection Control................................................................................................................................19

          Laboratory..........................................................................................................................................19-20

ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

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          Lease Agreements..............................................................................................................................20

          Maintenance Agreements...................................................................................................................20

          Medical Staff and Allied Health Professionals..................................................................................20-21

          Medical Waste Incinerator.................................................................................................................21

          Minutes ..............................................................................................................................................22

          Noise ..................................................................................................................................................22

          Nursing Records.................................................................................................................................22-23

          OSHA Records...................................................................................................................................23-24

          Planning .............................................................................................................................................24

          Permits, Licenses ...............................................................................................................................24

          Policy and Procedure Manuals...........................................................................................................24

          Physician Index..................................................................................................................................24

          Property Records................................................................................................................................25

          Purchasing..........................................................................................................................................25


ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                            Page 8 of 66
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                                                                                                                                                                 Record Retention Policy
          Safety / Security.................................................................................................................................25-26



                                                                                   Patient Accounting

          Cash Receipts.....................................................................................................................................27

          Collection...........................................................................................................................................27

          Medicare Secondary Payer Forms .....................................................................................................27



                                                                                              Finance

          Accounts Payable...............................................................................................................................28

          Accounts Receivable – Misc..............................................................................................................28-29

          Annual Report....................................................................................................................................29

          Audit ..................................................................................................................................................29

          Banking ..............................................................................................................................................29-30

          Budgeting...........................................................................................................................................30

ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

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          Capital Property .................................................................................................................................30-32

          Corporate Compliance Documentation..............................................................................................32

          Finance...............................................................................................................................................32-34

          Health Care Provider Tax ..................................................................................................................34

          Human Resources ..............................................................................................................................34

          Insurance ............................................................................................................................................34-35

          Intercompany .....................................................................................................................................35

          Journals / Ledgers ..............................................................................................................................35-36

          Payroll ................................................................................................................................................36-38

          Purchasing..........................................................................................................................................38

          Reimbursement ..................................................................................................................................38-39

          Shareholders.......................................................................................................................................39-40

          Tax .....................................................................................................................................................40-42

          Trust Documents................................................................................................................................42


ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

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                                                                                               Legal

          Articles of Incorporation....................................................................................................................43

          Bylaws................................................................................................................................................43

          Contracts ............................................................................................................................................43

          Copyright / Trademark / Patent..........................................................................................................43

          Corporate Compliance Documentation..............................................................................................43

          Insurance ............................................................................................................................................44

          Lease Agreements..............................................................................................................................44

          Litigation / Claims .............................................................................................................................44

          Minutes / Minute Books.....................................................................................................................45

          Mortgages / Promissory Notes...........................................................................................................45

          Property Records................................................................................................................................45

          Trust Documents................................................................................................................................45

ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

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                                                                                  Human Resources

          Accident / Injury Reports...................................................................................................................46

          Applications .......................................................................................................................................46

          Beneficiary Designations ...................................................................................................................46

          Benefit Reports ..................................................................................................................................46

          Disability Plan....................................................................................................................................46

          Educational Assistance Financing .....................................................................................................46

          Earnings Record.................................................................................................................................47

          Employee Hazardous Exposure Record.............................................................................................47

          Employee Medical Records ...............................................................................................................47

          Employee Requisition Files ...............................................................................................................47

          Flexible Spending Accounts ..............................................................................................................47

          Hazard Communication Record.........................................................................................................48

ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

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          Health Insurance Claims ....................................................................................................................48

          Incentive Plan Records ......................................................................................................................48

          Job Announcements ...........................................................................................................................48

          Layoff Records...................................................................................................................................48

          Life Insurance Records ......................................................................................................................49

          Paid Time Off Records ......................................................................................................................49

          Pay Scales ..........................................................................................................................................49

          Pension / 401(k) Retirement Plan Vesting Files ................................................................................49

          Personnel Action Request Forms.......................................................................................................49

          Personnel Files ...................................................................................................................................49

          Profit Sharing Records.......................................................................................................................50

          Radiation Exposure Records..............................................................................................................50

          Relocation Records ............................................................................................................................50

          Salary Surveys ...................................................................................................................................50


ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                          Page 13 of 66
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          Tax Payment Records ........................................................................................................................50

          Time Cards.........................................................................................................................................50

          Verification of Employment Eligibility.............................................................................................50

          W-2 Forms .........................................................................................................................................51



                                                                                        Miscellaneous

          Grants.................................................................................................................................................52



Kentucky Statute of Limitations.................................................................................................................53-54




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                           Page 14 of 66
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                                                               HOSPITAL / MEDICAL RECORDS

 TYPE                           NOTES                               RETAIN              AUTHORITY                                                     COMMENTS

 Ambulance Service              Run Report Forms -                5 Yrs                 902 KAR 14:080
 Records                        From Date Or Age Of
                                Majority

                                Personnel File Of                 5 Yrs                 902 KAR 14:080
                                Driver And Attendant
                                - From Last Date Of
                                Employment

 Cardiology / Cath
 Lab – See
 Diagnostics

 Chemical                       From Last Discharge               5 Yrs                 902 KAR 20:160
 Dependency                     After Age Of Majority             5 Yrs                 Sect. 3 (requires 3 yrs after the age
                                                                                        of majority)




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 15 of 66
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 TYPE                           NOTES                               RETAIN              AUTHORITY                                                     COMMENTS

 Death Records                  Dod, Name/Address                 5 Yrs                 KRS 213.146
 (adults and minors)            Of Who Body Is
                                Released To, Date Of
                                Removal

 Department Logs /              Examples:                         Adults-5 Yrs          No statutory / regulatory guideline                42 CFR 485.721 governs clinics
 Records                        Occupational Therapy              Minors-age                                                               and rehab agencies as providers of
 (except OB, ER, OR             Pulmonary Therapy                 of majority                                                              outpatient physical therapy and
 – see special rules)           Physical Therapy                  plus 5 Yrs                                                               speech-language pathology
                                Rehab                                                                                                      services
                                Sleep Disorders Lab
                                Speech Pathology




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 16 of 66
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 TYPE                           NOTES                               RETAIN              AUTHORITY                                                     COMMENTS

 Diagnostic Images              Raw data                          Adults-5 Yrs          No statutory / regulatory guideline
                                                                  Minors-age
                                                                  of majority
                                                                  plus 5 Yrs
                                Examples
                                Nuclear Medicine:
                                Patient Procedure Log
                                Radiation Film
                                 Monitoring Records
                                Radioactive Materials
                                 Licenses, Logs
                                Radioisotope Records
                                Regulatory Inspection
                                 Reports
                                Reports                                                 42 CFR 482.53 (5 yrs)




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 17 of 66
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 TYPE                           NOTES                               RETAIN              AUTHORITY                                                     COMMENTS

 Diagnostic Images              Examples
 (Continued)                    Other:
                                Cine Film, CD’s
                                EEG
                                EKG
                                Electrocardiogram
                                Electroencephalogram
                                Holter Monitor Log
                                Tracings
                                Vascular Study
                                Video Tapes
                                X-rays                                                  AHIMA (5 yrs)

 Disease Index                                                    10 Yrs                AHIMA                                              Electronically maintained by IS

 Equipment Records                                                Life of               No statutory / regulatory guideline
                                                                  Equipment
                                                                  Plus 2 Yrs




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 18 of 66
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 TYPE                           NOTES                               RETAIN              AUTHORITY                                                     COMMENTS

 Labs - Clinical                Proficiency Testing               2 Yrs From            42 CFR 493.801                                     All Laboratories must comply
 (CLIA Regulations)                                               Report Date                                                              with CLIA regulations at a
                                                                                                                                           Minimum. CAP has deemed
                                Test Records                      2 Yrs                 42 CFR 493.1107                                    status from CLIA, thus CAP
                                Test Reports                      2 Yrs                 42 CFR 493.1109                                    certified laboratories must follow
                                Quality Control Test              2 Yrs                 42 CFR 493.1221                                    CAP guidelines for record
                                                                                                                                           retention.

                                Immunohematology
                                Test Records                      5 Yrs                 42 CFR 493.1107                                    Note: State Laws supercede CAP
                                Test Reports                      5 Yrs                 42 CFR 493.1109                                    regulations.
                                Quality Control                   5 Yrs                 42 CFR 493.1221
                                   Records
                                Transfusion Records               5 Yrs                 42 CFR 493.1107
                                Discontinued Policies             2 Yrs                 42 CFR 493.1211
                                   & Procedures

                                Pathology
                                Test Reports                      10 Yrs                42 CFR 493.1109
                                Discontinued Policies             2 Yrs                 42 CFR 493.1211
                                   & Procedures




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 19 of 66
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 TYPE                           NOTES                               RETAIN              AUTHORITY                                                     COMMENTS

 Labs – Clinical                Discontinued Policies             2 Yrs                 1998.1 Edition – CAP                               All Laboratories must comply
 (CAP)                             & Procedures                                         General Checklist Questions                        with CLIA regulations at a
                                Specimen                          2 Yrs                 01.4148                                            minimum. CAP has deemed
                                   Requisitions                                                                                            status from CLIA, thus CAP
                                Test Results &                    2 Yrs                                                                    certified laboratories must follow
                                   Reports                                                                                                 CAP guidelines for record
                                Instrument Printouts              2 Yrs                                                                    retention.
                                Accession Records                 2 Yrs
                                Quality Control                   2 Yrs                                                                    Note: State Laws supercede CAP
                                   Records                                                                                                 regulations.
                                Proficiency Testing               2 Yrs
                                   Records
                                Quality Improvement               2 Yrs
                                   Records

                                Maintenance Records               Life of
                                                                  Analyzer

                                Serum and Body Fluid              24 hours
                                Specimens




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

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 TYPE                           NOTES                               RETAIN              AUTHORITY                                                     COMMENTS

 Labs – Clinical                Blood Films,                      7 Days
 (CAP)                          Permanently Stained
 (Continued)                    Body Fluid Slides and
                                Microbiology Slides

                                Pathology                                               1998.1 Edition – CAP
                                Accession Log                     2 Yrs                 Anatomic Pathology Checklist
                                   Records                                              Question 08.1250
                                Wet Tissue                        2 Weeks
                                Paraffin Blocks                   5 Yrs
                                Slides                            10 Yrs
                                Reports                           10 Yrs

                                Cytology                                                1998.1 Edition – CAP
                                Reports                           10 Yrs                Cytology Checklist Question
                                Slides                            5 Yrs                 08.A0690
                                Fine Needle                       10 Yrs
                                  Aspiration Slides




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

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 TYPE                           NOTES                               RETAIN              AUTHORITY                                                     COMMENTS

 Labs – Clinical                Immunohematology
 (CAP)                          / Transfusion
 (Continued)                    Services
                                Permanently Deferred              Indefinitely          1998.1 Edition – CAP
                                   Donors                                               Transfusion Medicine Checklist
                                                                  5 Yrs                 05.3225
                                Reports
                                                                  5 Yrs                 (See also 21 CFR 606.160(d) and
                                Donor & Recipient                                       42 CFR 493.1202 through
                                   Records                                              493.1221)
                                Records of Employee               5 Yrs
                                   Signatures
                                Initials                          5 Yrs
                                Identification Codes              5 Yrs
                                Donor & Recipient                 7 days Post-
                                                                  transfusion
                                    Specimens                     or at least 10
                                                                  days post-
                                                                  crossmatch

 Mammography                    Records Of                        10 Yrs                21 CFR 900.12 (c)(4)(i)
                                Screenings -From                                        KRS 304.17-316
                                Date Of Service                                         ACR


ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

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 TYPE                           NOTES                               RETAIN              AUTHORITY                                                     COMMENTS

 Master Patient Index           Dates Of Visits,                  Permanent             AHIMA                                              Electronically Maintained by IS
                                Names Of Physicians,                                    KRS 213.146 (5 yrs)
                                Record Of Diagnosis

 Medical Device                 Complaints And MDR                2 Yrs after           21 CFR 803.18
 Reporting                      Reports                           the event

 Medical Records                Original Or Legally               Adults - 10           902 KAR 20:016
                                Reproducible Form                 Yrs                   Sect. 3 (11) 2 (5 Yrs, majority plus
                                                                  Minors – age          3 Yrs)
                                                                  of majority           False Claims Act 31 USC 3731
                                                                  plus 5 Yrs            AHIMA / AHA (10 Yrs)

 Nuclear Medicine –
 See Diagnostices




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

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 TYPE                           NOTES                               RETAIN              AUTHORITY                                                     COMMENTS

 Obstetrics And                 Examples:                         Adults - 10           No statutory / regulatory guideline
 Gynecology                     Fetal Heart Monitor               Yrs                   AHIMA (10 Yrs)
                                Birth Records - Info              Minors – age          KRS 213.146 (5 Yrs)
                                   For Certificates               of majority
                                Patient Treatment                 plus 5 Yrs
                                   Records / Charts
                                Register / Log                                          AHIMA (permanent)
                                Ultrasounds On Video

                                Policy And Procedure              23 Yrs                No statutory / regulatory guideline
                                Manuals

 Operative Index                                                  10 Yrs                AHIMA                                              Electronically Maintained by IS

 Patient Complaints                                               2 Yrs                 No statutory / regulatory guideline

 Pharmacy                       Record Of Prescribed              2 Yrs                 KRS 217.895
                                Drugs Dispensed (All
                                Information)




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

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 TYPE                           NOTES                               RETAIN              AUTHORITY                                                     COMMENTS

 Pharmacy                       Records Of Controlled             2 Yrs                 KRS 218A.200
 (Continued)                    Substances Received                                     21 CFR 304.04
                                And Disposed

                                Computerized Record               5 Yrs                 201 KAR 2:170
                                Of Prescription And                                     21 CFR 304.04 (2 yrs)
                                Refills

                                Patient Records From              180 Days              201 KAR 2:210
                                Date Of Last Entry

                                Parenteral
                                Pharmaceutical
                                Compounding -
                                 Patient Profile From             Paper copy -          201 KAR 2:076
                                Last Dispension                   2 Yrs,
                                                                  Computer
                                                                  Data – 5 Yrs          201 KAR 2:076

                                MAR As Part Of                    5 Yrs From                                                               Retention should be the same as
                                 Medical Record                   Discharge                                                                the medical record, kept in the
                                                                                                                                           medical record


ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

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 TYPE                           NOTES                               RETAIN              AUTHORITY                                                     COMMENTS

 Pharmacy                       Sale Of Hypodermic                2 Yrs                 KRS 217.177
 (Continued)                    Needles - Name,
                                Address, Quantity,
                                Date Of Sale, Planned
                                Use

 Sterilization /                                                  5 Yrs                 AAMI (The Association for the
 Autoclave Records                                                                      Advancement of Medical
                                                                                        Instrumentation)

 Surgery                                                          5 Yrs                 No statutory / regulatory guideline
 Register/Log




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 26 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy
                                                                             HOME HEALTH

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Clinical Records                                                 Adult -10             42 CFR 484.48(a)
                                                                  Yrs                   False Claims Act 31 USC
                                                                  Minor – age           3731
                                                                  of majority
                                                                  plus 3 Yrs




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 27 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy
                                                        HOSPITAL / ADMINISTRATIVE RECORDS

 TYPE                           NOTES                               RETAIN              AUTHORITY                                                  COMMENTS

 Accreditation                  Record Of                         Permanent             No statutory / regulatory
                                                                                        guideline

                                JCAHO & State                     Permanent             No statutory / regulatory
                                Licensure Surveys                                       guideline

 Contracts                                                        10 Yrs                No statutory / regulatory
                                                                  Following             guideline
                                                                  Termination
                                                                  Date

 Dietary                        Food Cost                         5 Yrs                 No statutory / regulatory
                                Includes:                                               guideline
                                Budgets
                                Expense reports

                                Inspection Reports                3 Yrs                 No statutory / regulatory
                                                                                        guideline

                                Inventory                         2 Yrs                 No statutory / regulatory
                                                                                        guideline



ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 28 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                               RETAIN              AUTHORITY                                                  COMMENTS

 Dietary                        Meal Counts                       2 Yrs                 No statutory / regulatory
 (Continued)                                                                            guideline

                                Menus                             2 Yrs                 902 KAR 20:016 (30 days)
                                Purchase Orders                   3 Yrs                 No statutory / regulatory
                                                                                        guideline

                                Sales Receipts                    5 Yrs                 No statutory / regulatory                  Kept for Tax purposes
                                                                                        guideline

                                Staff Schedules                   2 Yrs                 No statutory / regulatory
                                                                                        guideline

 Education                      BCLS, ACLS, PALS                  5 Yrs                 No statutory / regulatory
                                Records                                                 guideline

                                CE Program Summary                5 Yrs                 No statutory / regulatory                  Retention periods based on
                                Forms & Attendance                                      guideline                                  requirements of JCAHO and survey
                                                                                                                                   process.
                                CE Course Outlines                5 Yrs                 No statutory / regulatory
                                                                                        guideline




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 29 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                               RETAIN              AUTHORITY                                                  COMMENTS

 Education                      New Hire Orientation              5 Yrs                 No statutory / regulatory
 (Continued)                                                                            guideline


                                Nursing CE And                    5 Yrs                 KBN Regulations
                                Inservice Records                                       (24 CFR 585.401 – 3 yrs)

                                CPR Certification                 5 Yrs                 No statutory / regulatory
                                                                                        guideline

 Employee Medical               Period Of                         30 Yrs                29 CFR 1910.20
 Records                        Employment Plus

 Engineering                    Construction Projects             15 Yrs after          No statutory / regulatory
                                                                  completion            guideline

                                Blueprints / Drawings             Permanent             No statutory / regulatory
                                                                                        guideline

                                Equipment Records                 Life Of               No statutory / regulatory
                                (Operating Manual,                Equipment             guideline
                                Inspection,                       Plus 2 Yrs
                                Maintenance)


ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 30 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                               RETAIN              AUTHORITY                                                  COMMENTS

 Engineering                    ETO And Steam Log                 5 Yrs                 No statutory / regulatory
 (Continued)                    Book                                                    guideline


                                Fire Drill And Alarm              3 Yrs                 No statutory / regulatory
                                Reports, Training                                       guideline
                                Records

                                Inspection Of                     3 Yrs                 No statutory / regulatory
                                Grounds                                                 guideline

                                Inspections –                     3 Yrs                 No statutory / regulatory
                                Electrical                                              guideline
                                Distribution, Elevator,
                                Incinerator, Grounds,
                                Buildings

                                Licenses / Permits                Permanent             No statutory / regulatory
                                Licenses / Permits -                                    guideline
                                Building




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 31 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                               RETAIN              AUTHORITY                                                  COMMENTS

 Engineering                    Preventive                        Warranty              No statutory / regulatory
 (Continued)                    Maintenance Records               Period plus 1         guideline
                                (Non-Clinical                     Yr or 3 Yrs
                                Equipment)                        (whichever is
                                                                  longest)

                                Service Contracts                 10 Yrs                Statute of Limitations in
                                                                  following             Kentucky
                                                                  termination

                                Special Waste                     Permanent             No statutory / regulatory
                                Hauling                                                 guideline

 Housekeeping                   Staff Schedules                   2 Yrs                 No statutory / regulatory
                                                                                        guideline
                                Room Records                      3 Yrs                 No statutory / regulatory
                                                                                        guideline
                                Procedures / Polices              5 Yrs                 No statutory / regulatory
                                                                                        guideline




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 32 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                               RETAIN              AUTHORITY                                                  COMMENTS

 Incident Reports               Visitor Incidents                 2 Yrs                 No statutory / regulatory                  Electronically maintained beyond the
                                                                                        guideline                                  retention period by IS.
                                Patient Incidents                 3 Yrs                 No statutory / regulatory
                                                                                        guideline
                                Minors                            Age of                No statutory / regulatory
                                                                  Majority plus         guideline
                                                                  3 Yrs

 Infection Control              Training Records –                3 Yrs                 No statutory / regulatory
                                training materials,                                     guideline
                                attendance record

                                Communicable                      5 Yrs                 No statutory / regulatory
                                Disease Reports                                         guideline

                                Infection Control                 5 Yrs                 No statutory / regulatory                  Kept By Infection Control Nurse
                                Surveillance                                            guideline

                                Nosocomial                        3 Yrs                 No statutory / regulatory
                                Worksheet                                               guideline

 Laboratory                     Staffing Schedules                2 Yrs                 No statutory / regulatory
                                                                                        guideline


ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 33 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                               RETAIN              AUTHORITY                                                  COMMENTS

 Laboratory                     Minutes                           3 Yrs                 No statutory / regulatory
 (Continued)                                                                            guideline

 Lease Agreements                                                 10 Yrs                No statutory / regulatory
                                                                  Following             guideline
                                                                  Termination
                                                                  Date

 Maintenance                                                      10 Yrs                No statutory / regulatory
 Agreements                                                       Following             guideline
                                                                  Termination
                                                                  Date

 Medical Staff and              Minutes                           Permanent             No statutory / regulatory                  Note: Regulations re: credentials,
 Allied Health                                                                          guideline                                  minutes, etc., require they be made part
 Professionals                                                                                                                     of permanent record of hospital
                                Bylaws                            Permanent             No statutory / regulatory                  administration.
                                                                                        guideline

                                Credentialling Files              Permanent             No statutory / regulatory
                                                                                        guideline




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 34 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                               RETAIN              AUTHORITY                                                  COMMENTS

 Medical Staff and              Inactive Medical Staff            Permanent             No statutory / regulatory
 Allied Health                  Files                                                   guideline
 Professionals
 (Conintued)                    Peer Review                       Permanent             No statutory / regulatory
                                Committee Minutes                                       guideline

                                Physician Contracts               10 Yrs                No statutory / regulatory
                                                                  Following             guideline
                                                                  Termination

 Medical Waste                  records and manifest              3 Yrs                 401 KAR 32:040
 Incinerator

                                records of CEMS,                  2 Yrs                 401 KAR 59:023
                                steam flow,
                                temperature data

                                names and dates of                2 Yrs from            401 KAR 61:013
                                persons required to               date of
                                review operating                  review
                                manual and
                                documentation



ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 35 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                               RETAIN              AUTHORITY                                                  COMMENTS

 Minutes                        Department Minutes                3 Yrs                 No statutory / regulatory
                                                                                        guideline

 Noise                          monitoring records                duration of           29 CFR 1910.95
                                that are part of                  employment
                                audiometric record

                                monitoring records                2 Yrs                 29 CFR 1910.95

 Nursing Records                Staff Schedules                    5 Yrs                No statutory / regulatory
                                                                                        guideline

                                Committee Minutes                 3 Yrs                 No statutory / regulatory
                                                                                        guideline

                                Policies / Procedures             5 Yrs                 No statutory / regulatory
                                                                                        guideline

                                QA Studies / Reports              3 Yrs                 No statutory / regulatory
                                                                                        guideline




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 36 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                               RETAIN              AUTHORITY                                                  COMMENTS

 Nursing Records                Orientation Records /             Term Of               No statutory / regulatory
 (Continued)                    Skills Checklist                  Employment            guideline
                                                                  plus 3 Yrs

                                Logbooks                          5 Yrs                 No statutory / regulatory
                                                                                        guideline

                                Crash Cart Check Log              3 Yrs                 No statutory / regulatory
                                                                                        guideline

                                Infection Control                 5 Yrs                 No statutory / regulatory                  Kept By Infection Control Nurse
                                Surveillance                                            guideline

 OSHA Records                   log of occupational               5 Yrs                 29 CFR 1904.2 and 1904.4                   Recordable Occupational Injuries and
                                injuries/illnesses                                                                                 Illness

                                Employee records of               30 Yrs                29 CFR 1910.20
                                exposure, medical                                       29 CFR 1910.1048
                                records of                                              (formaldehyde)
                                examination, analysis
                                of records




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 37 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                               RETAIN              AUTHORITY                                                  COMMENTS

 OSHA Records                   Bloodborne Pathogen               3 Yrs                 29 CFR 1910.1030
 (Continued)                    Training Records


 Planning                       CON Application And               Permanent             No statutory / regulatory
                                CHR Approvals                                           guideline

 Permits, Licenses                                                Permanent             No statutory / regulatory
                                                                                        guideline

 Policy And                     Policies And                      5 Yrs                 Policy And Procedure
 Procedure Manuals              Procedures                                              Manuals

                                Ob / Gyn                          Permanent             Policy And Procedure
                                                                                        Manuals

 Physician Index                Record of Procedures              10 Yrs                AHIMA
                                Done by Physicians




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 38 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                               RETAIN              AUTHORITY                                                  COMMENTS

 Property Records               Deeds                             Permanent             No statutory / regulatory
                                                                                        guideline
                                Title Insurance                   Permanent

                                Environmental Survey              Permanent

 Purchasing                     Capital Budget                    3 Yrs                 No statutory / regulatory
                                Purchasing Orders                                       guideline

                                Delivery Tickets /                1 Yr After            No statutory / regulatory
                                Packing Slips                                           guideline

                                Purchase Orders                   7 Yrs                 No statutory / regulatory
                                                                                        guideline

                                Requisitions                      1 Yr                  No statutory / regulatory
                                                                                        guideline

                                Signatory Authority               Permanent             No statutory / regulatory
                                For Purchases                                           guideline

 Safety / Security              Duty Logs                         3 Yrs                 No statutory / regulatory
                                                                                        guideline


ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 39 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                               RETAIN              AUTHORITY                                                  COMMENTS

 Safety / Security              Emergency Action /                5 Yrs                 No statutory / regulatory
 (Continued)                    Preparedness Plans                                      guideline

                                Incident Reports                  3 Yrs                 No statutory / regulatory
                                Examples:                                               guideline
                                Theft reports
                                Visitor falls
                                Incidents involving
                                security intervention

                                Policies and                      5 Yrs                 No statutory / regulatory
                                Procedures                                              guideline

                                Safety Committee                  3 Yrs                 No statutory / regulatory
                                Reports / Minutes                                       guideline

                                Security Management               5 Yrs                 No statutory / regulatory
                                Plan                                                    guideline

                                Tour Report (Ground               3 Yrs                 No statutory / regulatory
                                Inspections)                                            guideline




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 40 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy
                                                                      PATIENT ACCOUNTING

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Cash Receipts                  Includes Medicare                 7 Yrs                 No statutory / regulatory
                                Remittances                                             guideline


 Collection                     Collection Records                Tax Return            26 CFR 301.6501(E)-1                       Records related to the management and
                                                                  Filing Date +                                                    collection of bad debts
                                                                  10 Yrs

                                Bad Debt Reports                  Tax Return            26 CFR 301.6501(E)-1                       Reports detailing bad debts write-offs
                                                                  Filing Date +
                                                                  10 Yrs

 Medicare Secondary                                               10 Yrs                No statutory / regulatory
 Payer Forms                                                                            guideline




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 41 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy
                                                                                  FINANCE

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Accounts Payable               Check Register                    CY + 6 Yrs            26 CFR 301.6501(E)-1

                                Invoices / Vouchers               CY + 6 Yrs            26 CFR 301.6501(E)-1
                                Examples:
                                Credit Card
                                   Statements
                                Donations
                                Expense reports
                                Petty Cash
                                Reimbursement
                                   Request
                                Insurance Payments
                                   (Unemployment,
                                    Worker’s Comp)

 Accounts                       Cash Receipts                     CY + 6 Yrs            26 CFR 301.6501(E)-1
 Receivable – Misc.
 (does not include              Credit Advices                    CY + 6 Yrs            26 CFR 301.6501(E)-1                       Records documenting payments which
 patient accounting)                                                                                                               result in credit due
                                Invoices                          CY + 6 Yrs            26 CFR 301.6501(E)-1




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 42 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Accounts                       Reconciliations                   CY + 6 Yrs            26 CFR 301.6501(E)-1                       Reports and workpapers used to
 Receivable – Misc.                                                                                                                reconcile account receivable accounts
 (Continued)

                                Sales Receipts                    CY + 6 Yrs            26 CFR 301.6501(E)-1                       Retain daily summary logs (not daily
                                                                                                                                   receipt tapes)

 Annual Report                                                    CY + 10 Yrs           26 CFR 301.6501(E)-1                       Retained by BHS

 Audit                          External Reports                  CY + 10 Yrs           26 CFR 301.6501(E)-1                       Retained by BHS

                                Internal Reports                  CY + 6 Yrs            No statutory / regulatory                  Retained by BHS
                                                                                        guideline

                                Workpapers                        CY + 3 Yrs            No statutory / regulatory                  Records supporting audit reports,
                                                                                        guideline                                  prepared as part of the audit process

 Banking                        Bank Deposits                     CY + 6 Yrs            26 CFR 301.6501(E)-1

                                Bank Reconciliations              CY + 6 Yrs            26 CFR 301.6501(E)-1

                                Bank Statements                   CY + 6 Yrs            26 CFR 301.6501(E)-1




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 43 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Banking                        Check Registers                   CY + 6 Yrs            26 CFR 301.6501(E)-1
 (Continued)

                                Check Copies / Stubs              CY + 6 Yrs            No statutory / regulatory
                                                                                        guideline

                                Checks Paid / Cleared             CY + 6 Yrs            26 CFR 301.6501(E)-1

                                Transaction Notices               CY + 6 Yrs            26 CFR 301.6501(E)-1

                                Wire Transfers                    CY + 6 Yrs            26 CFR 301.6501(E)-1

 Budgeting                      Budgets Approved                  CY + 1 Yr             No statutory / regulatory                  Retained by BHS
                                                                                        guideline

                                Budget & Variance                 CY + 1Yr              No statutory / regulatory                  Budget versus actual with variance
                                Reports                                                 guideline

                                Workpapers                        CY + 1 Yr             No statutory / regulatory
                                                                                        guideline

 Capital Property               Acquisitions                      CY + 6 Yrs            26 CFR 1.167(A)-11,12                      Records documenting the purchase of
                                                                                        26 CFR 301.6501(E)-1                       property and equipment


ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 44 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Capital Property               Capital Asset Records             CY + 6 Yrs            26 CFR 1.167(A)-11,12                      Records documenting the purchase and
 (Continued)                                                                            26 CFR 301.6501(E)-1                       sale of property and equipment,
                                                                                                                                   including depreciation, improvements,
                                                                                                                                   tax credit, and depletion

                                Capital Expenditure               CY + 6 Yrs            26 CFR 1.167(A)-11,12
                                Receipts and Reports                                    26 CFR 301.6501(E)-1

                                Construction                      CY + 6 Yrs            26 CFR 1.167(A)-11,12                      Construction in progress reports, cost
                                Accounting Reports                                      26 CFR 301.6501(E)-1                       analysis reports, etc.
                                and Workpapers

                                Depreciation                      CY + 6 Yrs            26 CFR 1.167(A)-11,12                      Reports and workpapers detailing
                                Schedules and                                           26 CFR 301.6501(E)-1                       deprecation, gain/loss and sales of fixed
                                Workpapers                                                                                         assets

                                Fixed Asset Schedules             CY + 6 Yrs            26 CFR 1.167(A)-11,12
                                                                                        26 CFR 301.6501(E)-1

                                Material Transfer                 CY + 6 Yrs            26 CFR 1.167(A)-11,12                      Records documenting physical transfer
                                Files                                                   26 CFR 301.6501(E)-1                       of material and property from one
                                                                                                                                   location to another and the related
                                                                                                                                   transfer of accounting charges


ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 45 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Capital Property               Property Inventory                CY + 6 Yrs            26 CFR 1.167(A)-11,12                      Records documenting the type, model
 (Continued)                                                                            26 CFR 301.6501(E)-1                       and location of property and equipment

                                Property Sold                     CY + 6 Yrs            26 CFR 1.167(A)-11,12
                                                                                        26 CFR 301.6501(E)-1

 Corporate                                                        Permanent             No statutory / regulatory
 Compliance                                                                             guideline
 Documentation

 Finance                        Bonds / Debentures                Year of cash          26 CFR 1.167(A)-11,12                      Records related to corporate debentures
                                and Workpapers                    defeasance +          26 CFR 301.6501(E)-1                       and corporate bonds, as well as
                                                                  7 Yrs                                                            workpapers related to analysis of
                                                                                                                                   corporate debt
                                Credit Agency                     CY + 2 Yrs            No statutory / regulatory
                                Reports                                                 guideline

                                Financial Statements              CY + 2 Yrs            No statutory / regulatory                  Retained by BHS
                                Monthly / Quarterly                                     guideline




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 46 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Finance                        Investments                       CY + 7 Yrs            26 CFR 1.167(A)-11,12
 (Continued)                    Examples:                                               26 CFR 301.6501(E)-1
                                Investment reports
                                Real estate purchase
                                Purchase of Securities
                                Annual statements

                                Leases                            10 Yrs after          No statutory / regulatory
                                                                  termination           guideline

                                Letters of Credit                 6 Yrs after           26 CFR 1.167(A)-11,12                      Retained by BHS
                                                                  termination           26 CFR 301.6501(E)-1

                                Loan Applications,                6 Yrs after           26 CFR 1.167(A)-11,12
                                Agreements                        termination           26 CFR 301.6501(E)-1

                                Mortgage Records                  10 Yrs after          No statutory / regulatory
                                                                  termination           guideline

                                Notes                             6 Yrs after           26 CFR 301.6501(E)-1
                                                                  termination




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 47 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Finance                        Planning (Financial)              CY + 6 Yrs            No statutory / regulatory
 (Continued)                    Examples:                                               guideline
                                Forecast
                                Projections
                                Strategic development

 Health Care                    Records, Receipts,                6 Yrs                 KRS 142.341
 Provider Tax                   Invoices

 Human Resources                Flexible Spending                 CY + 6 Yrs            29 CFR 2610.11                             Journal entry support documents.
                                Accounts                                                29 USC 113

                                Paid Time Off                     CY + 6 Yrs            29 CFR 2610.11                             Journal entry support documents.
                                Records                                                 29 USC 113

 Insurance                      Policies And Related              CY + 6 Yrs            806 KAR 2:070
                                Documents                         or Expiration
                                Example:
                                Trust Reconciliations




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 48 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Insurance                      Policies And 3rd Party            10 Yrs                No statutory / regulatory
 (Continued)                    Payor Contracts                   Following             guideline
                                Example:                          Termination
                                Managed Care                      Date

 Intercompany                   Invoices                          CY + 6 Yrs            26 CFR 301.6501(E)-1                       Invoices detailing intercompany account
                                                                                                                                   transactions

 Journals / Ledgers             Accounts Payable                  CY + 6 Yrs            26 CFR 301.6501(E)-1
                                Monthly Distribution

                                Accounts Receivables              CY + 6 Yrs            26 CFR 301.6501(E)-1
                                Ledgers

                                Cash Journals                     CY + 6 Yrs            26 CFR 301.6501(E)-1

                                Chart of Accounts                 CY + 6 Yrs            26 CFR 301.6501(E)-1                       Listing of account names and codes used
                                                                                                                                   in the accounting system

                                General Ledger /                  CY + 6 Yrs            26 CFR 301.6501(E)-1                       Consolidated, cumulative general ledger
                                Subsidiary Ledgers                                                                                 or subsidiary ledgers published at year
                                                                                                                                   end (Detailed General Ledger Kept
                                                                                                                                   Electronically or on Microfiche)


ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 49 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Journals / Ledgers             Monthly Close                     CY + 6 Yrs            26 CFR 301.6501(E)-1                       Accounting workpapers processed at the
 (Continued                     Package                                                                                            closing of the monthly general ledger

                                Journal Entries and               CY + 6 Yrs            26 CFR 301.6501(E)-1                       Records detailing transactions and
                                Adjustments                                                                                        corrections in the general ledger
                                Examples:
                                Cash receipts
                                Intercompany
                                Corrections

                                Purchase or Sale of               Tax Return
                                Entities / Affiliates /           Filing Date +
                                Joint Venture                     15 Yrs

                                Trial Balances                    CY + 6 Yrs            No statutory / regulatory
                                                                                        guideline

 Payroll                        Checks Paid / Cleared             CY + 6 Yrs            26 CFR 301.6501(E)-1                       Checks issued for payroll that have been
                                                                                                                                   cashed and returned by the bank

                                Earnings Records                  CY + 6 Yrs            29 CFR 1627.3                              Records summarizing earning of
                                                                                                                                   individual employees




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 50 of 66
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 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Payroll                        Garnishment                       CY + 6 Yrs            26 CFR 301.6501(E)-1                       Records related to the withholding and
 (Continued)                    Accounting                                                                                         payment to third parties of amounts
                                                                                                                                   garnished from employee wages

                                Garnishment Orders                Active                No statutory / regulatory
                                                                  Orders + 1            guideline
                                                                  Yr

                                Payroll Records                   CY + 6 Yrs            26 CFR 31.6001-1                           Records documenting payments for
                                                                                        26 CFR 301.6501(E)-1                       payroll over time including dates,
                                                                                                                                   employee names, withholding amounts
                                                                                                                                   and purpose, final check amounts and
                                                                                                                                   other related information.

                                Payroll Registers                 CY + 6 Yrs            26 CFR 301.6501(E)-1                       Records detailing payroll amounts,
                                                                                                                                   deductions, and taxes for each employee

                                Payroll Reports and               CY + 6 Yrs            26 CFR 31.6001-1
                                Workpapers                                              26 CFR 301.6501(E)-1

                                Payroll                           CY + 6 Yrs            26 CFR 31.6001-1
                                Reconciliations                                         26 CFR 301.6501(E)-1




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 51 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
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 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Payroll                        Time Cards                        2 Yrs                 KRS 337.320
 (Continued)
                                W-2                               CY + 6 Yrs            26 CFR 301.6501(E)-1

 Purchasing                     Bids Accepted                     CY + 6 Yrs            No statutory / regulatory
                                                                                        guideline

                                Catalogs / Price List             Until                 No statutory / regulatory
                                                                  superseded            guideline

                                Purchase Orders                   CY + 6 Yrs            26 CFR 301.6501(E)-1

                                Receiving                         CY + 6 Yrs            26 CFR 301.6501(E)-1
                                documentation

 Reimbursement                  Correspondence                    CY + 15 Yrs           No statutory / regulatory
                                Examples:                         after                 guideline
                                OIG Request                       Medicare
                                With HHS                          Appeals
                                With Fiscal                       Process
                                  Intermediaries




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 52 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Reimbursement                  Cost reports and                  CY + 15 Yrs           42 CFR 413.20
 (Continued)                    workpapers, filed and             after                 42 CFR 413.24
                                audited                           Medicare
                                                                  Appeals
                                                                  Process

                                Cost report appeals               CY + 15 Yrs           42 CFR 413.20
                                and workpapers, filed             after                 42 CFR 413.24
                                and audited                       Medicare
                                                                  Appeals
                                                                  Process

                                Cost report support               CY + 15 Yrs           42 CFR 413.20                              Supporting documents used to construct
                                papers                            after                 42 CFR 413.24                              the cost report
                                                                  Medicare
                                                                  Appeals
                                                                  Process

 Shareholders                   Correspondence Keep               3 Yrs                 KRS 271B.16-010
                                At Principal Office
                                For




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 53 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Shareholders                   Financial Statements              3 Yrs                 KRS 271B.16-010
 (Continued)                    Given To - Keep At
                                Principal Office For

 Tax                            Federal Tax returns,              Tax return            26 CFR 301.6501(E)-1
                                reports, workpapers               filing date +
                                and correspondence                15 Yrs
                                Examples:
                                Income tax
                                Excise tax
                                Employment tax
                                IRS Audit reports
                                Protest
                                Appeals
                                Claims for Refunds




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 54 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Tax                            State and Local tax               Tax return            KRS 131.6001 (requires 5
 (Continued)                    returns, reports,                 filing date +         Yrs after filing return)
                                workpapers and                    15 Yrs
                                correspondence
                                Examples:
                                Income tax
                                Employment tax
                                IRS Audit reports
                                Protest
                                Appeals
                                Claims for Refunds

                                Form 1099                         CY + 6 Yrs            26 CFR 301.6501(E)-1

                                Form 940 / 941                    CY + 6 Yrs            26 CFR 301.6501(E)-1

                                Health Care Provider              Tax return            KRS 142.314                                Records, receipts and invoices
                                Tax                               filing date +
                                                                  6 Yrs

                                Research Files                    CY + 6 Yrs            26 CFR 301.6501(E)-1                       Research files for tax issues




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 55 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
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 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Tax                            Tax Compliance Files              Tax return            26 CFR 301.6501(E)-1
 (Continued)                                                      filing date +
                                                                  10 Yrs

 Trust Documents                Examples:                         CY + 10 Yrs           No statutory / regulatory
 (Health, Workers               Policies                                                guideline
 Comp, Malpractice)             Workpapers
                                Statements




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 56 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy
                                                                                    LEGAL

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Articles of                                                      Permanent             No statutory / regulatory                  Includes Affiliated Corporations and
 Incorporation                                                                          guideline                                  Joint Ventures


 Bylaws                                                           Permanent             No statutory / regulatory                  Includes Affiliated Corporations and
                                                                                        guideline                                  Joint Ventures

 Contracts                                                        10 Yrs                No statutory / regulatory
                                                                  Following             guideline
                                                                  Termination
                                                                  Date

 Copyright /                    Records of rights                 6 Yrs                 35 USC 286
 Trademark / Patent             conveyed

 Corporate                                                        Permanent             No statutory / regulatory
 Compliance                                                                             guideline
 Documentation




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 57 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Insurance – see also           Policies And Related              5 Yrs After           806 KAR 2:070
 Trust Documents                Documents                         Termination
                                                                  or Expiration

                                Record Of Insurance               5 Yrs                 No statutory / regulatory
                                                                                        guideline

                                Claims Made Policies              Indefinitely          No statutory / regulatory
                                                                                        guideline

                                Policies And 3rd Party            Permanent             No statutory / regulatory
                                Payor Contracts                                         guideline

 Lease Agreements                                                 10 Yrs                No statutory / regulatory
                                                                  Following             guideline
                                                                  Termination
                                                                  Date

 Litigation / Claims            Medical Malpractice               10 Yrs After          Statute of Limitations
                                                                  Final
                                                                  Disposition



ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 58 of 66
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                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Minutes / Minute               Board of Directors /              Permanent             No statutory / regulatory                  Includes Affiliated Corporations and
 Book                           Shareholders                                            guideline                                  Joint Ventures
                                                                                                                                   May be put in Storage 2 years after
                                                                                                                                   dissolution of the Corporation.

 Mortgages /                    After satisfaction                10 Yrs                No statutory / regulatory
 Promissory Notes                                                                       guideline

 Property Records               Deeds                             Permanent             No statutory / regulatory
                                                                                        guideline
                                Title Insurance                   Permanent             No statutory / regulatory
                                                                                        guideline
                                Environmental Survey              Permanent             No statutory / regulatory
                                                                                        guideline

 Trust Documents                Examples:                         CY + 10 Yrs           No statutory / regulatory
 (Health, Workers               Policies                                                guideline
 Comp, Malpractice)             Workpapers
                                Statements




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 59 of 66
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                                                                                                                                                Record Retention Policy
                                                                         HUMAN RESOURCES

 TYPE                           NOTES                             RETAIN                AUTHORITY                                  COMMENTS

 Accident / Injury              Job-related accidents             5 Yrs                 29 CFR 1904.6
 Reports                        and injuries

 Applications                   Rejected, individuals             1 Yr                  29 CFR 1627.3
                                not hired

 Beneficiary                                                      6 Yrs from            29 CFR 1627.3
 Designations                                                     revision or           29 USC 1027
                                                                  payout

 Benefit Reports                Govt required reports             5 Yrs                 29 CFR 30.8(E)
                                relating to benefits
                                and benefit plans

 Disability Plan                Employee eligibility              6 Yrs                 29 CFR 1627.3
                                and benefits under the                                  29 USC 1027
                                plan

 Educational                    From last action date             6 Yrs                 29 CFR 2610.11
 Assistance                                                                             29 USC 113
 Financing



ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 60 of 66
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                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                  COMMENTS

 Earnings Record                Records summarizing               7 yrs                 29 CFR 1627.3
                                earnings of individual
                                employees

 Employee                                                         30 Yrs                29 CFR 1910.20
 Hazardous Exposure                                                                     29 CFR 1910.1001
 Records

 Employee Medical               Related to hazardous              30 Yrs                29 CFR 1910.20
 Records                        exposure                                                29 CFR 1910.1001

 Employee Medical               Not related to                    5 Yrs                 29 CFR 1904.6
 Records                        hazardous exposure

 Employee                       Related to requisition            3 Yrs                 29 CFR 1627.3
 Requisition Files              of new employees

 Flexible Spending                                                7 Yrs                 29 CFR 2610.11
 Accounts                                                                               29 USC 113




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 61 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
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 TYPE                           NOTES                             RETAIN                AUTHORITY                                  COMMENTS

 Hazard                         Communication of                  30 Yrs                29 CFR 1910.20
 Communication                  information about                                       29 CFR 1910.1001
 Records                        hazardous substances
                                or situations

 Health Insurance               Benefits received,                6 Yrs                 29 CFR 2610.11
 Claims                         claims, summary                                         29 USC 113
                                reports,
                                correspondence, etc.

 Incentive Plan                 Benefits received,                6 Yrs                 29 CFR 2610.11
 Records                        summary reports, etc.                                   29 USC 113

 Job Announcements              Notice of job                     1 Yr                  29 CFR 1627.3
                                openings
                                communicated in the
                                media or other means

 Layoff Records                 Related to corporate              6 Yrs                 29 CFR 1620.33
                                labor force reductions                                  29 CFR 1602.14
                                                                                        29 CFR 1627.2-.3




ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 62 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                  COMMENTS

 Life Insurance                 Benefits received                 6 Yrs                 29 CFR 2610.11
 Records (Group)                claims, summary                                         29 USC 113
                                reports,
                                correspondence, etc.

 Paid Time Off                  Time accrued and                  6 Yrs                 29 CFR 2610.11
 Records                        used                                                    29 USC 113

 Pay Scales                     Charts used to                    6 Yrs                 29 CFR 1627.3
                                determine salary for
                                job classifications

 Pension / 401(k)               Employees vested                  10 Yrs                29 USC 1059
 Retirement Plan                under the plan and
 Vesting Files                  eligible for payments

 Personnel Action               Used by HR to                     6 Yrs                 29 CFR 1620.33
 Request Forms                  create/change                                           29 CFR 1602.14
                                employee information                                    29 CFR 1627.2-.3

 Personnel Files                Personnel actions,                6 Yrs after           29 CFR 1620.33
                                evaluations, salary,              termination           29 CFR 1602.14
                                etc.                                                    29 CFR 1627.2-.3


ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 63 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy

 TYPE                           NOTES                             RETAIN                AUTHORITY                                  COMMENTS

 Profit Sharing                 Benefits received,                6 Yrs                 29 CFR 2610.11
 Records                        correspondence,                                         29 USC 113
                                summary reports, etc.

 Radiation Exposure                                               30 Yrs                29 CFR 1910.20
 Records                                                                                29 CFR 1910.1001

 Relocation Records             From last action date             6 Yrs                 29 CFR 2610.11
                                                                                        29 USC 113

 Salary Surveys                                                   6 Yrs                 29 CFR 1627.3

 Tax Payment                    Kentucky                          7 Yrs                 KRS 131.185
 Records

 Time Cards                                                       2 Yrs                 KRS 337.320

 Verification of                INS Form I-9                      3 Yrs                 8 CFR 274A.2
 Employment
 Eligibility

 W-2 Forms                                                        7 Yrs                 26 CFR 301.6501(E)-1
                                                                                        (requires 6 Yrs after return
                                                                                        filed)

ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 64 of 66
                                                                                                                                         Baptist Healthcare System, Inc.
                                                                                                                                                Record Retention Policy
                                                                           MISCELLANEOUS

 TYPE                           NOTES                             RETAIN                AUTHORITY                                                  COMMENTS

 Grants                         records kept pursuant             3 Yrs or til          45 CFR 74.53 and
                                to 45 CFR Part 74 -               resolution of         42 CFR
                                from date of final                any actions
                                expenditure report or
                                quarterly/annual
                                report

                                Federal for                       Same                  42 CFR 51c.112
                                community health
                                service projects


                                National Heart, Lung,             Same                  42 CFR 52a.8
                                and Blood Institute

                                National Cancer                   Same                  42 CFR 52b.6
                                Institute

                                Dept. Local                       5 Yrs from            KRS 42.355
                                Government re:                    completion
                                capital projects



ACR=American College of Radiology, AHA = American Hospital Association, AHIMA = American Health Information Management Association, CAP=College of American Pathologists, CFR =
Code of Federal Regulations, CY = Current Year, KAR = Kentucky Administrative Regulations, KRS = Kentucky Revised Statutes

                                                                                Page 65 of 66
                                                                                       Baptist Healthcare System, Inc.
                                                                                              Record Retention Policy
                                KENTUCKY STATUTE OF LIMITATIONS
                                  Note: Age of Majority in Kentucky is 18


 Actions Not Provided For In Statutes                             10 Yrs               KRS 413.160

 Action Upon Bill Of Exchange                                     5 Yrs                KRS 413.120

 Breach Of Contract For Sale                                      4 Yrs                KRS 355.2-725

 Default Of Lease Contract                                        4 Yrs                KRS 355.2A-506

 Fraud/Mistake
   From Discovery                                                 5 Yrs                KRS 413.120
   From Date Of Occurrence                                        10 Yrs               KRS 413.130

 Libel / Slander                                                  1 Yr                 KRS 413.140

 Malpractice / Personal Injury
  From Discovery                                                  1 Yr                 KRS 413.245
  From Date Of Occurrence                                         5 Yrs                KRS 413.140

 Oral Contract                                                    5 Yrs                KRS 413.120

 Trespass Of Real Or Personal Property                            5 Yrs                KRS 413.120

 Wrongful Death / Injury To Person Due To                         7 Yrs                KRS 413.135
 Construction Of Improvement Of Real Property

 Wage Discrimination Because Of Sex                               6 mos from           KRS 337.430
                                                                  occurrence

 Discrimination - As Filed With Commission On                     180 days from        KRS 344.200
 Human Rights                                                     occurrence

 Upon Final Order May File With Circuit Court                     30 days              KRS 13B.140




                                                        Page 66 of 66

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