Office of Compliance Programs
Document Retention Policy and Procedure Training for Department
Revised: February 16, 2017
LSUHSC-NO must comply with state and federal records retention
requirements in order to provide appropriate access to state
information to the public and to limit the potential liability of the
University in a legal proceeding. This tutorial will explain the
requirements of the law and how to comply with LSUHSC-NO’s Records
- Retention Policy and Schedule
- Correct identification of records
- Proper disposal of records
- Appropriate “hold” procedures for litigation and audits
- Repercussions and potential legal liability if procedures are not
followed correctly and consistently.
Louisiana’s Public Records Act (LA R.S. 44.1 et seq.) requires that
“...a statewide system of managing and preserving government records
which will meet informational requirements and serve the rights and
interest of government and its citizens...” be developed. This system
is administered through the Louisiana Division of Archives, Records
Management and History located in the Secretary of State’s Office.
The Division of Archives, Records Management and History is required
to establish standards and guidelines to ensure the state's official
records are created and maintained efficiently, economically, and in a
manner that guarantees their public accessibility. Additionally, the
law requires that each state agency designate a Records Officer to work
with the Division of Archives, Records Management, and History
regarding that agency's records management needs.
LSUHSC-NO’s Records Officer is designated by the Chancellor annually.
What is Considered a Record?
Louisiana Revised Statutes 44:402 defines a Record as “all:
- magnetic or optical media,
- motion picture
- other document or any other material,
regardless of physical form or characteristic, generated or received
under law or in connection with the transaction of official business,
or preserved by an agency or political subdivision because of other
informational or legal value.”
What is not considered a “Record”?
The term "record" shall not be construed to include:
- library and museum material developed or acquired and preserved
solely for reference or exhibition purposes,
- extra copies maintained for convenience in reference or
- stocks of standard publications, or processed documents.
Content of the Record
The content, or what the record is about, controls the length of
time that the records must be maintained. For example, emails regarding
patient care should be maintained for the same retention period as the
retention period of paper patient care records.
Scope of LSUHSC-NO's Retention Policy
This policy applies to all records (written, electronic or any other
form) maintained by the LSUHSC-NO campus, including but not limited to:
- Education Records
- Clinical Records and Patient Communications
- Human Resource Records
- Research Records
- Public Records
Appendix A of the LSUHSC-NO Records Retention Policy contains the
definitions of the above categories of records.
LSUHSC-NO’s Records Retention Policy and Schedule
In order to comply with the legal retention requirements, the
University has created the LSUHSC-NO Records Retention and Disposition
Policy and Records Retention Schedule. Both the policy and
schedule can be found on the Office of Compliance Programs (OCP)
The Retention Schedule organizes the University's records into
Record Series based on the content of the records and time amount of
time the records should be retained.
The Retention Period is the amount of time that a record in a record
series must be retained prior to its destruction. This is usually
expressed in terms of the number of years after the record is actively
Destruction of Records
Once the Retention Period for a set of records has expired,
LSUHSC-NO may request permission from Division of Archives, Records
Management and History to destroy the
records. The process for obtaining permission to destroy records is as
Step 1: Identification of Retention Period of the Records to be
- Once the major category of records has been identified, consult
the LSUHSC-NO Records Retention Schedule.
- Under the major category designations, there are subcategories
which determine the retention period for those types of records.
- According to the Louisiana Public Records Act, all records the
University maintains must be kept for the current year plus three
years. However, longer federal or contractual retention periods may
- If you are unsure what major category or subcategory to which a
particular record set belongs, contact the Office of Compliance
Programs or LSUHSC-NO Records Officer.
- In accordance with R.S. 44:411, written approval shall be
obtained from the State Archivist (or his designee) prior to the
disposing of any records of the agency.
- If records you wish to destroy do not fall under any category on
LSUHSC-NO’s Document Retention Schedule, contact the Office of
Compliance Programs to initiate the process to add line items of record
types prior to destroying the documents.
Step 2: Obtain Approval from State Archives
- Complete Form SS ARC 930. If there is a small number
of items to be destroyed you can list them directly on the form. When
destroying several different types of records you can attach a
spreadsheet of the items for sections #6 and #7 on the form.
- The form can be found on the Office of Compliance Programs
- See examples of completed spreadsheets on the Office of
Compliance Programs website.
- Send a scanned copy of the completed form with the attached
listing (if necessary) to email@example.com.
- Once the documents are ready, OCP will forward the documents to
LSUHSC-NO’s Records Officer for submission to State Archives. Note:
LSUHSC-NO’s Records Officer will sign and date the form as the
- You will be notified by email when written approval for the
destruction of the records from State Archives has been received.
Step 3: Disposal of Records-Paper
- The acceptable methods of destruction will be included on the
- Complete the Certificate of Destruction Form SS ARC 933 to
document the date of destruction. In the event that a third party
shredding company is used for destruction, the date the records are
transferred to the shredding company will constitute the destruction
- You must document the destruction of the records by maintaining
Certificate of Destruction form (SS ARC 933) along with the approved
request for destruction received back from State Archives (SS ARC 930).
Disposal of Records--Electronic
Permission to destroy electronic records must be obtained as
described above for paper records. Electronic records that contain
Protected or Restricted information (as defined by PM-36) must be
disposed of in accordance with PM-36.
In certain cases, the destruction of records must be put on “hold”
even though the retention period has expired.
Litigation and Audit Holds
- When there is actual or potential for litigation to arise out of
event, such as termination of employees, sexual harassment,
discrimination, whistleblower claims, etc., the Department Records
Liaison shall notify the Department Head.
- The Department Head will confer with Legal Counsel to determine
what records need to be designated on hold for litigation or audit
- The Records Officer will issue a hold notification, in writing,
the Department Liaison/Business Manager, indicating the effected
information/records not to be destroyed.
- The Department Liaison/Business Manager is responsible to
notify to department employees that destruction of any documents
related to the pending matter shall be postponed until the hold is
- Once the audit or litigation hold is no longer necessary, the
Records Officer will notify the Department Liaison/Business Manager
that destruction of the records may be requested.
Consequences of Non-compliance with Policy
Failure to place a hold on records relevant to the litigation and
those records are subsequently destroyed may cause a presumption in the
litigation that those records would have been harmful to LSUHSC-NO’s
In the court case, Zubulake v. UBS Warburg, the defendant UBS was
held accountable for the negligent destruction of emails and other
documents, even though the employee was following the company’s
published records retention policy.
The key failure the court found was that there was a “reasonable
expectation” a lawsuit would be filed and therefore, normal retention
procedures should have been suspended.
While a litigation hold may have been in place, the employee was
not trained in the proper procedures for suspending the normal
After the conclusion of this case, both the federal and state court
systems amended the rules of procedure to prevent parties from
destroying documents relevant to the litigation.
Failure to comply with the LSUHSC-NO Records Retention policy may
place the University at risk of liability for not being able to
properly respond to records requests in the following ways:
- Public Records Requests
- Audit Investigations, both internal and external
- Litigation Proceedings
Recent Event involving Records Retention
- In February 2009, it was discovered pursuant to a public records
request by the New Orleans Times Picayune that every email sent and
received by then New Orleans Mayor Ray Nagin was apparently deleted.
- The courts determined that this was an apparent violation of the
state public records law and a violation of his own office’s technology
- The mayor’s office did not have a backup process for its
electronic files, contrary to it’s own policy.
- Nagin asserts that only 15 of the email messages and half of his
calendar for 2008 could be retrieved.
- In court documents, Nagin stated that he sent and received 50 to
100 email messages a day.
- State law defines “injuring of public records” as the intentional
removal, mutilation, destruction or alteration, falsification or
concealment of any record, document, or other thing filed or deposited…
in any public office or with any public officer.”
- Violations of the law are punishable by as long as five years in
prison and fines of as much as $5,000.
- On March 4, 2009, the court assessed a fine against the City of
Orleans of $7000 for failure to comply with the state public records
law amounting to $100 per day for each day the records were not turned
If you have
any questions, please contact the Office of