SAMPLE POLICY WORK

– The Quality Assurance Team audits a random sample of records monthly to ensure adherence to protocols. 3. Security and Confidentiality Compliance: – IT personnel implement multi ‑ factor authentication, encryption, and secured backups to protect digital records. – Physical records are stored in locked, fire ‑ resistant filing cabinets located in restricted areas. – All access to sensitive records is logged automatically by the system with a full audit trail. 4. Retention and Destruction Protocol: – Records are classified by type and assigned a retention period according to regulatory requirements. – Automated reminders in the system notify the Responsible Manager when records are eligible for review or secure destruction. – Upon expiration of the retention period, records are securely destroyed using approved methods (i.e., shredding for paper documents, secure deletion protocols for digital records). A destruction log is maintained to document this process.

5.

Record Retrieval and External Audits:

– Authorized personnel can retrieve records using the system’s search functionality. – Digital dashboards provide real ‑ time access to record logs and audit trails. – External auditors are provided with read ‑ only access to the centralized system upon request, and all queries are logged and tracked.

Implementation Checklist Task

Responsible Party

Frequency

Verification Method

Create new records upon data reception

All staff

Immediately upon receipt

Unique identifiers and timestamps in the system Electronic logs and supervisor verification Meeting minutes, spot ‑ checks, internal audit reports

Daily/Shift ‑ end

Update records with new information within 24 hours Perform weekly departmental reviews of records Conduct monthly Quality Assurance audits Secure IT backup and encryption of

Direct Support, Clinical, & Admin Staff

Department Heads/Supervisors

Weekly

QA and Compliance Teams

Monthly

Automated audit trails, QA reports

IT and Records Management

Daily/Weekly

Backup logs, encryption validation

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