general retention and disposal authority: public health ... · general retention and disposal...

General retention and disposal authority: public health services –

patient/client records

PO Box 516

Kingswood NSW 2747

Tel: 02 9673 1788 Fax: 02 9833 4518

ABN: 96 588 554 718

www.records.nsw.gov.au

State Archives and Records Authority of New South Wales 1 of 32

Overview

Purpose of the authority

The purpose of the General Retention and Disposal Authority - Public Health Services:

Patient/Client records is to identify which patient/client records are required as State

archives and to permit public health services and facilities to destroy certain other

patient/client records after minimum retention periods have been met.

In particular this authority covers:

records relating to the management, treatment and care of individual patients and

clients within the NSW public health system, including records of allied health care

services and Ambulance, emergency and non-emergency patient transport

services

records relating to the administration of patient and client information and

provision of services to them

records relating to the provision of diagnostic imaging and pathology and

laboratory services

records relating to the supply, administration, dispensing and use of

pharmaceuticals

records of notifications or reporting to prescribed bodies prescribed bodies or

authorities in accordance with statutory or other requirements records relating to the conduct of research.

Patient/client health care records

Patient and client health care records document an individual’s health evaluation,

diagnosis, treatment, care, progress and health outcome. These records should be

created and maintained in accordance with NSW Health policy and directives concerning

the creation, maintenance, retention and disposal of patient/client records and

information.

Records relating to the provision of treatment and care to a patient/client include (but

are not limited to) records relating to or of a patient's/client’s:

admission, including medical and nursing records

history (medical and social of the patient or their family)

examination results (physical or other)

transfer, referral or assessment

correspondence between the patient or their representative and the health care

service

consultation reports (medical or other)

principal diagnosis and any other significant diagnosis

medication or drug orders and medication administered or prescribed (including

oral, parenteral and incident reports)

nursing care (including all versions or revisions of nursing care plans) and clinical

pathways observations

counselling, allied health, social work or other health care professional notes


allergies or special conditions

doctor’s or physician’s orders

all observations and progress notes

requests for and results or reports of all laboratory, diagnostic or investigative

tests or procedures performed (including pathology, X-ray or other medical

imaging examinations)

consent or authority to carry out any treatment, procedure or release of

information and certification that consent is informed (including removal or

donation of tissue or organs, consent to special procedures, participate in

research, etc.)

refusal of treatment or withdrawal of consent

prenatal, obstetric, newborn and perinatal treatment, care and outcomes

(includes newborn records and perinatal morbidity statistics)

surgical procedure or operation (including pre-operative checklists, anaesthetic

records and peri operative nurses reports including instrument and swab count

records and post operative observations)

all therapeutic treatments or procedures (including anti-coagulant, diabetic,

dialysis, electric shock therapy (EST) and electro convulsive therapy (ECT))

statements made for the Police and Coronial Inquest Reports

discharge (includes final diagnosis, operative procedures, summary or letter of

discharge and discharge at own risk or against advice)

death (includes autopsy or post-mortem reports).

Implementing the authority

Unless specified, the minimum retention periods and disposal actions identified in this

authority apply to records irrespective of format (paper, digital or other).

Records required as State archives

Records which are to be retained as State archives are identified with the disposal action

'Required as State archives'. Records that are identified as being required as State

archives should be transferred to the State Archives and Records Authority of NSW when

they are no longer in use for official purposes.

The transfer of control of records as State archives may, or may not, involve a change in

custodial arrangements. Records can continue to be managed by the public office under a

distributed management agreement. Public offices are encouraged to make

arrangements with State Archives and Records regarding the management of State

archives.

Transferring records identified as State archives and no longer in use for official purposes

to State Archives and Records’ control should be a routine and systematic part of a public

office's records management program. If the records are more than 25 years old and are

still in use for official purposes, then a 'still in use determination' should be made.


Records approved for destruction

The approval for destruction given by this authority is given under the provisions of the

State Records Act 1998 only and does not override any other obligations of an

organisation to retain records for longer where there is an identified need or obligation to

do so.

Retention periods set down in this authority are minimum periods only. Records that

have been identified as being approved for destruction may only be destroyed once a

public office has ensured that all other requirements for retaining the records are met. A

public office should keep records for a longer period if necessary. Reasons for longer

retention can include other statutory or regulatory requirements, research need, and

government directives. A public office must not dispose of any records where the public

office is aware of possible legal action (including legal discovery, court cases or formal

Inquiries, formal applications for access) where the records may be required as evidence.

Once all requirements for retention have been met, destruction of records should be

carried out in a secure and environmentally sound way.

Regardless of whether a record has been approved for destruction or is required as a

State archive, a public office or an officer of a public office must not transfer possession

or ownership of a State record to any person or organisation without the explicit approval

of the State Archives and Records Authority of NSW.

General retention and disposal authority: public health services -


List of Functions and Activities covered


Function Activity Reference Page

PATIENT/CLIENT TREATMENT

AND CARE

6

Hospital and emergency care 1.1.0 6

Community based health care 1.2.0 8

Oral (dental) health care 1.3.0 9

Obstetric/maternal health care 1.4.0 10

Psychiatric and mental health

care

1.5.0 10

Genetic or inherited disorders 1.6.0 12

Assisted Reproductive

Technology (ART)

1.7.0 12

Sexual assault patients 1.8.0 13

Physical abuse and neglect 1.9.0 14

Radiotherapy treatment 1.10.0 14

Complaints and incident

management

1.14.0 15

Surgical procedures and

sterilisation of equipment

16

PATIENT/CLIENT REGISTRATION

AND MANAGEMENT

18

Patient/client registration 2.1.0 18

Patient/client administration

(includes finance, property and

disability equipment)

2.8.0 20

DIAGNOSTIC SERVICES 23

Imaging and recording services 3.0.0 23

Pathology and laboratory

services

4.0.0 24

PHARMACEUTICAL SUPPLY AND

ADMINISTRATION

27

Dispensing and supply 5.1.0 27

List of Functions and Activities covered


Function Activity Reference Page

NOTIFICATIONS 29

Health reporting 6.2.0 29

RESEARCH MANAGEMENT 30

Research projects, trials or

studies

8.1.0 30

PRE-1930 PATIENT/CLIENT

RECORDS & COLLECTIONS OR

SAMPLES OF PATIENT/CLIENT

RECORDS

32

General retention and disposal authority: public health services -


No. Description of records Disposal action


PATIENT/CLIENT TREATMENT AND CARE

The provision of health assessment, diagnosis, management, treatment and care services

and/or advice to individual patients/clients.

See PRE-1930 PATIENT/CLIENT RECORDS & COLLECTIONS OR SAMPLES OF

PATIENT/CLIENT RECORDS for records created prior to 1930 and for Collections or

samples of patient records identified as being of continuing value for medical or social

research purposes..

See RESEARCH MANAGEMENT for records relating to the conduct of clinical audits for

the purposes of evidence based quality management

1.1.0 Hospital and emergency care

The provision of treatment, care and services to hospital inpatients, outpatients and

accident and emergency patients. Includes the provision of treatment, care and services

by ambulance and other emergency transport services.

1.1.1 PATIENT/CLIENT TREATMENT AN D CARE - H ospital and em ergency care

Records documenting the treatment and care of

admitted patients of Group A hospitals.

Retain minimum of

15 years after last

attendance or official

contact or access by

or on behalf of the

patient or until

patient attains or

would have attained

the age of 25 years,

whichever is longer,

then destroy

Justification/Remarks: Consistent with current minimum retention requirements

applying to Group A Hospitals - Records of discharged or deceased inpatients (GDA17,

1.1.1).

Retention periods encompass expected requirements for clinical care, research and

potential legal action, with regard to type of facility and nature of care provided. Group

A hospitals are generally principal referral hospitals providing specialist, acute care,

research and teaching services hence longer retention periods have been identified for

these types of facilities.



admitted patients of Group B hospitals and services.

Retain minimum of

10 years after last



or on behalf of the

patient or until

patient attains or

would have attained



then destroy


General retention and disposal authority: public health services

Patient/client records


PATIENT/CLIENT TREATMENT AND CARE - Hospital and emergency care


applying to Groups B-F Hospitals - Records of discharged or deceased inpatients

(GDA17, 1.1.2).

Retention periods encompass expected requirements for clinical care, research and

potential legal action, with regard to type of facility and nature of care provided. Group

B facilities include nursing homes, rehabilitation facilities, hospices, Multi Purpose

Services and hospitals that are not Group A Principal Referral, Paediatric Specialist or

un-Grouped Acute hospitals.



patients attending or presenting at emergency or out-

patient clinics that are not admitted as patients,

including patients who are dead on arrival.

Retain minimum of 7

years after last



or on behalf of the

patient or until

patient attains or

would have attained



then destroy


applying to patients of all hospital groups attending or presenting to Emergency or Out

Patient Departments not admitted as inpatients (GDA17, 1.1.3).

Retention periods encompass expected requirements for clinical care and potential

legal action.



ambulance, emergency and non emergency transport

service patients/clients. Includes inter-hospital

transfers of non-emergency patients.

Retain minimum of 7

years after

attendance/provision

of service or after

last official contact

or access by or on

behalf of the patient

or until patient

attains or would

have attained the

age of 25 years,


then destroy

Justification/Remarks: New entry - records not previously covered.

Retention period consistent with periods applying to patients attending or presenting at

emergency or out-patient clinics (entry 1.1.3 above). Background information

previously provided by NSW Ambulance Services indicates standard practice is for a

copy of records documenting patient diagnosis, condition and treatment provided

during emergency transport to be passed to and incorporated into the hospital record

of treatment and care.


Records documenting the receipt of and action taken

in response to emergency calls or communications.

Retain minimum of 7

years after action




PATIENT/CLIENT TREATMENT AND CARE - Community based health care


Includes recordings of calls, vehicle dispatch and

arrival details, etc.

completed, then

destroy

Justification/Remarks: New entry - records not previously covered.

Retention period consistent with periods applying to similar records in the Victorian

jurisdiction (Public Records Office of Victoria retention and disposal authority

Ambulance Service functions PROS 10/08, entry 3.1.1).

1.2.0 Community based health care

The provision of treatment and care to patients/clients through community based health

care facilities, centres or services. This includes unregistered clients, clients who are only

'visitors', clients who are screened without follow up, potential clients or clients who are

referred elsewhere.

1.2.1 PATIENT/CLIENT TREATMENT AN D CARE - C ommunity bas ed health c are

Records documenting the provision of treatment, care,

assessment, screening and other services to

community clients. Includes:

immunisations

audiology and eyesight screenings

breast screening and other imaging services

child, family health and school screening.

Retain minimum of

7 years after last

attendance or

official contact or

access by or on

behalf of the client

or until patient

attains or would

have attained the

age of 25 years,


then destroy

If TB

(tuberculosis)

service:

Retain minimum of

15 years after last

attendance or

official contact by or

on behalf of the

patient or until

patient attains or

would have attained


then destroy


applying to Community health care - Client health records and immunisation and

screening records where an abnormality is detected (GDA17, 1.2.1, 1.2.3, 1.2.5 and

1.2.7).

Increases minimum retention requirements for all immunisation and screening records

of minors (GDA17, 1.2.4 and 1.2.6) to until would have attained the age of 25

years, irrespective of whether or not an abnormality is detected.




PATIENT/CLIENT TREATMENT AND CARE - Community based health care


Increases minimum retention requirements for TB (Chest Clinic) services from 7 to 15

years after last attendance or official contact.

Retention periods encompass expected requirements for clinical care and research and

potential legal action, with regard to type of facility and nature of care provided.

Longer retention period for TB services (Chest Clinics) based on recommendation from

Ministry of Health (Office of the Chief Health Officer, Director Communicable Diseases,

Health Protection NSW).

1.2.8 PATIENT/CLIENT TREATMENT AN D CARE - C ommunity bas ed health c are

Criminal histories of clients referred by Courts under

rehabilitation or treatment programs e.g. Magistrates

Early Referral into Treatment (MERIT) Program.

Retain until

conclusion of

client's active

involvement in

program, then

destroy


applying to criminal histories of clients of the Magistrates Early Referral into Treatment

(MERIT) Program (GDA17, 1.2.8).

Reflects the period of use of the record for purposes required, as per Memoranda of

Understanding between NSW Health and NSW Police.

1.3.0 Oral (dental) health care

The provision of treatment, care and services to clients of oral (dental) health care

services.

1.3.1 PATIENT/CLIENT TREATMENT AN D CARE - Oral (dental) health c are

Records documenting the examination, assessment

and treatment of dental patients/clients. Includes

dental charts, consent forms, x-rays etc.

Retain minimum of

7 years after last

attendance or

official contact or

access by or on

behalf of the client

or until patient

attains or would

have attained the

age of 25 years,


then destroy


applying to oral (dental) health care records (GDA17, 1.3.1). Increases retention

requirements for school dental risk assessment consent forms from minimum of 2

years to until age of 25 reached.

Retention periods encompass expected requirements for clinical care and potential

legal action. This is in line with retention periods for other community health care

records.




PATIENT/CLIENT TREATMENT AND CARE - Obstetric/maternal health care


1.4.0 Obstetric/maternal health care

The management of births, including adoption processes. Includes any pregnancy that

results in the birth of a baby where birth registration is required under the Births, Deaths

and Marriages Act, including live and still births.

See PATIENT/CLIENT TREATMENT AND CARE - Hospital and ambulance care and

Community Health care for records relating to the care and treatment of mother and

child.

1.4.1 PATIENT/CLIENT TREATMENT AN D CARE - Obstetric/maternal health car e

Records documenting birth episodes. Includes:

the mother's antenatal records, including any

antenatal screening results

records of the labour, including CTG traces

medical records relating to the neonatal period

and following.

Retain minimum of

30 years after date

of birth or minimum

of 15 years after

last official contact

or access by or on

behalf of the

patient, whichever

is longer, then

destroy

Justification/Remarks: Currently records documenting birth episodes are required to

be retained indefinitely (GDA17, entry 1.4.1).

Based on recommendation of Ministry of Health (MoH) retention for a minimum of 30

years after date of birth or minimum of 15 years after last access by or on

behalf of the patient, whichever is longer is proposed. MoH has advised that it is

more likely than not that obstetric negligence claims would be commenced within 30

years of birth, therefore amending the retention period from 'indefinite' to 30 years

would be unlikely to create a problem for any future claims.

Registers of births will continue to be required as State archives (entry 2.1.2).

Description amended to provide more detail about what constitutes birth records. This

is based on MoH advice regarding the types of records required as evidence in obstetric

negligence claims against NSW public health organisations.

1.4.2 PATIENT/CLIENT TREATMENT AN D CARE - Obstetric/maternal health car e

Records documenting arrangements for adoptions that

proceed. Includes associated social work, counselling

or support records.

Retain in agency

Justification/Remarks: Consistent with current retention requirements applying to

social work records relating to instances of arrangements for adoptions (GDA17, entry

1.4.2 - retain indefinitely). The Adoption Act 2000 provides a right to access

information held by public hospitals, therefore MoH recommends that the current

indefinite retention requirements for these records be maintained.

Registers of births will also continue to be required as State archives (entry 2.1.2).

1.5.0 Psychiatric and mental health care

The provision of treatment, care and services to patients under mental health legislation

e.g. the Mental Health Act.




PATIENT/CLIENT TREATMENT AND CARE - Psychiatric and mental health care


See PATIENT/CLIENT TREATMENT AND CARE - Hospital care or Community

Health Care for records relating to the treatment and care of patients not covered by

the Mental Health Act who have mental health conditions.

See PATIENT/CLIENT TREATMENT AND CARE - Significant patient records for

collections or samples of patient records identified as being of continuing value for

medical or social research purposes.

1.5.1 PATIENT/CLIENT TREATMENT AN D CARE - Psychiatric and mental health car e

Records of patients/clients of former Crown

operated/5th Schedule psychiatric hospitals where the

records were wholly or partly created prior to 1960.

Required as State

archives

Justification/Remarks: Consistent with current requirements applying to

patient/client records of former Crown operated/5th Schedule psychiatric hospitals

created prior to 1960 (GDA17, 1.5.1).

Retention of pre 1960 records documents period of in-patient care in primarily large

institutions, where patient admissions tended to be involuntary and the services

performed a custodial as well as a therapeutic role. Complete collections of post 1960

records of some facilities are also already held as State archives and provide a

resource documenting shifts in medical approaches to the treatment and care of

psychiatric patients. There is also the potential for additional post 1960 collections of

records to be transferred under 10.2.0 (Collections of samples of patient records of

significance).

1.5.3 PATIENT/CLIENT TREATMENT AN D CARE - Psychiatric and mental health car e


patients/clients under mental health legislation e.g. the

Mental Health Act.

Retain minimum of

25 years after last

attendance or

official contact or

access by or on

behalf of the patient

or until patient

attains or would

have attained the

age of 43 years,


then destroy

Justification/Remarks: This entry will supersede GDA17 entry 1.5.2.

Increase in current minimum retention requirements from 15 years after last

attendance or access by or on behalf of the patient or until patient attains age 25 to

minimum of 25 years after last attendance or access by or on behalf of the

patient or until patient attains age 43, whichever is longer.

Increase in retention period recommended by Mental Health and Drug and Alcohol

Office (MHDAO), Ministry of Health, to enable records to be accessed for ongoing

clinical research and other purposes. Mental health patients can be detained and

involuntarily treated. The increase in retention period would also allow details of

patients who may not present for treatment for some time to be kept, which is

important given that many consumers receive mental health care and treatment across

their lifespan.




PATIENT/CLIENT TREATMENT AND CARE - Genetic or inherited disorders


1.6.0 Genetic or inherited disorders

The diagnosis of genetic or inherited disorders.

See PATIENT/CLIENT TREATMENT AND CARE - Hospital care or Community

Health Care for records relating to the treatment and care of patients with a genetic or

inherited disorder.

1.6.1 PATIENT/CLIENT TREATMENT AN D CARE - G enetic or inherited d is orders

Records documenting the diagnosis of patients with

genetic or inherited disorders by specialist genetics

units.

Retain in agency


records documenting the diagnosis of a genetic or inherited disorder (GDA17, entry

1.6.1). Scope of application has been amended to limit application to records

maintained by specialist genetics units only.

The current GDA17 requirement of indefinite retention may be interpreted as applying

to all patient/client records relating to or documenting the diagnosis of a genetic or

inherited disorder. Genetic disorders are increasingly being diagnosed by non-genetics

health professionals however it is impractical for medical records departments to have

a system for identifying general medical records where a patient has been diagnosed

with a genetic condition, therefore many public health organisations cannot comply

with the existing requirements. Where genetic disorders are diagnosed by non-genetics

health professionals it is likely that the individual will still be referred to a genetics

service for the purposes of confirmation of the diagnosis, additional information about

the condition, decision-making about genetic testing, discussion of implications for

genetic relatives, etc. This means that there is still a dedicated genetics record that is

created, even though the diagnosis was made by a non-genetics professional. It is

appropriate that dedicated genetic records continue to be retained indefinitely for

research purposes.

1.7.0 Assisted Reproductive Technology (ART)

The provision of assisted reproductive technology services.

See PATIENT/CLIENT TREATMENT AND CARE - Obstetric/maternal health care

for records documenting birth episodes.

1.7.3 PATIENT/CLIENT TREATMENT AN D CARE - Ass isted Reproductive Technol ogy (ART)


assisted reproductive technology patient/clients.

Retain prescribed

information in

accordance with

legislative

requirements, all

other records

maintain for

minimum of 15

years after last

access by or on

behalf of the

patient, then




PATIENT/CLIENT TREATMENT AND CARE - Sexual assault patients


destroy

Justification/Remarks:

This entry will supersede GDA17 entries 1.7.1 and 1.7.2.

Section 31 of the Assisted Reproductive Technology Act 2007 currently requires ART

providers to retain the following records for 50 years after the record is made

irrespective of whether or not a pregnancy is achieved:

the identity of each gamete provider and any prescribed information about their

spouse (if any) and offspring

the provenance of any such gamete or embryo

the gamete provider’s consent.

uses made of any gamete or embryo

the period of storage

the identity of each woman who undergoes ART treatment

any other prescribed information about the woman, the woman’s spouse (if any)

and any offspring of the woman

the identity and any other prescribed information about each offspring born as a

result of ART treatment provided by the ART provider.

GDA17 currently distinguishes applicable retention requirements based on whether or

not a pregnancy is achieved (75 years if pregnancy achieved (GDA17, 1.7.1), 15 years

where a pregnancy is not achieved (GDA17 1.7.2)). This is potentially inconsistent with

current legislative requirements.

To avoid potential inconsistency between retention requirements identified by

legislation regulating ART procedures and the requirements of the State Records Act

the disposal action has been amended to allow for retention and disposal of ART

related records in accordance with current applicable legislative requirements. Longer

retention periods than those currently identified in GDA17 may apply to

certain records to comply with requirements of the Assisted Reproductive

Technology Act.

1.8.0 Sexual assault patients

The provision of treatment and care to victims of sexual assault.

1.8.1 PATIENT/CLIENT TREATMENT AN D CARE - S exual as sault patients


victims of sexual assault or abuse.

Retain minimum of

30 years after

completion of any

legal action or after

last contact for

legal access or

minimum of 30

years after the

individual attains or

would have attained

the age of 18,




PATIENT/CLIENT TREATMENT AND CARE - Physical abuse and neglect



then destroy


applying to records relating to the provision of treatment and care to patients in

instances of sexual assault (GDA17, 1.8.1).

Retention periods based on potential evidentiary requirements for legal purposes (e.g.

records of physical examination).

1.9.0 Physical abuse and neglect

The treatment and care of victims of physical abuse and neglect. Includes children,

young people, and mandatory reporting cases.

1.9.1 PATIENT/CLIENT TREATMENT AN D CARE - Physic al abuse and neglect

Records documenting the provision of treatment and

care to victims of physical abuse and neglect subject to

mandatory reporting. This includes instances of the

abuse and neglect of children, young people and other

vulnerable persons such as the elderly, disabled or

persons in care subject to mandatory reporting.

Retain minimum of

30 years after

completion of any

legal action or after

last contact for

legal access or

minimum of 30

years after the

individual attains or

would have attained

the age of 18,


then destroy


applying to client records of Physical Abuse and Neglect of Children (PANOC) Specialist

Services (GDA17, 1.9.1). Scope extended to apply more broadly e.g. elderly, disabled

or persons in care where instances of suspected abuse and neglect are subject to

mandatory reporting.

Retention periods based on potential legal and evidentiary requirements.

1.10.0 Radiotherapy treatment

The delivery of radiation treatment to radiotherapy patients.

1.10.2 PATIENT/CLIENT TREATMENT AN D CARE - R adiotherapy treatment

Records documenting radiation dose delivery to

patients undergoing radiotherapy treatment. Includes

external radiotherapy, as well as internal radiotherapy

(such as radioisotope and brachytherapy).

Retain minimum of

15 years after

patient would have

attained the age of

70 or minimum of

15 years after last

attendance,


then destroy




PATIENT/CLIENT TREATMENT AND CARE - Complaints and incident management



Increases current retention requirements applying to records documenting radiation

dose delivery to patients (admitted and non-admitted) who have undergone

radiotherapy treatment (GDA17, 1.10.1) from 10 years to minimum of 15 years after

age of 70, date of death or last attendance.

Increase in retention requirements based on recommendation of Health System

Information and Performance Reporting, MoH to better support oncology research.

Retention period encompasses expected requirements for clinical care (re radiation

dosage) and research and potential legal action and enables destruction of records of

deceased patients where notification of death has been received through Cancer

Registry or other systems.

1.14.0 Complaints and incident management

The activities relating to the management of complaints from or incidents involving

patients/clients.

See General Retention and Disposal Authority Administrative records LEGAL SERVICES

- Litigation for records relating to complaints, incidents or claims that result in legal

action and for the handling of subpoenas and discovery orders.

See General Retention and Disposal Authority Administrative records GOVERNMENT

RELATIONS - Advice for records relating to the reporting of critical incidents

See General Retention and Disposal Authority Public health Services: Administrative

records CLINICAL SERVICES - Incident management for records relating to

rectification action taken in response to an incident or complaint or the monitoring of

complaints and occurrence of incidents

1.14.6 PATIENT/CLIENT TREATMENT AN D CARE - C omplaints and incident management

Registers or equivalent summary records of

patient/client complaints, injuries or incidents.

Retain minimum of

30 years after last

action or last entry

in register (if hard

copy), then destroy


applying to registers of patient injuries (GDA17, 1.14.6).

Retention period enables access for reference in case of potential legal action, including

minors.

1.14.7 PATIENT/CLIENT TREATMENT AN D CARE - C omplaints and incident management

Records relating to the handling of complaints and

investigation of incidents concerning the provision of

patient/client treatment or care. This includes

associated reports of and records of investigations into

an incident or complaint.

Retain minimum of

7 years after action

completed or until

the patient/client

attains or would

have attained the

age of 25,


then destroy




PATIENT/CLIENT TREATMENT AND CARE - Surgical procedures and instruments



Consistent with current minimum retention requirements applying to records of

complaints and incidents not involving legal action (GDA17, 1.14.3). Increases

minimum retention period for complaints and incidents involving minors to until would

have attained the age of 25 years. Retention period enables access for reference in

case of further claims or potential legal action. Amended retention period is consistent

with retention requirements applying to records relating to subsequent rectification

action taken in response to an incident, for example the implementation of

recommendations of an investigation under the General retention and disposal

authority: public health services - administrative records (CLINICAL SERVICES -

Incident management, GDA21, 2.5.1).

Where a complaint or incident results in legal action retention requirements as outlined

in the General retention and disposal authority: administrative records (LEGAL

SERVICES - Litigation) will apply.

Surgical procedures and sterilisation of equipment

The management of instruments, items and equipment used in surgical and medical

procedures.

See PATIENT/CLIENT TREATMENT AND CARE - Hospital care for accountable item

and sterile instrument tracking forms which are maintained as part of the patient file.

See PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client

registration for registers of surgically implanted devices or prostheses.

1.17.1 PATIENT/CLIENT TREATMENT AN D CARE - Surgical procedures and instruments

Records relating to the sterilisation of surgical

instruments and equipment, e.g. log books, registers.

Retain minimum of

15 years after

action completed,

then destroy


applying to records relating to the sterilisation of surgical instruments and equipment

used in procedures (GDA17, 1.17.1 and 1.17.2).

Retention period encompasses potential legal enquiries/litigation.

1.18.1 PATIENT/CLIENT TREATMENT AN D CARE - Surgical procedures and instruments

Records of accountable items used in operating

theatres e.g. instruments and swab counts.

Originals are to be

retained as per

records of

patient/client

treatment and care,

duplicate copies

retain minimum of

1 year after action

completed, then

destroy


applying to originals and duplicates of accountable items (GDA17, 1.18.1).




PATIENT/CLIENT TREATMENT AND CARE - Surgical procedures and instruments


Retention period encompasses potential legal enquiries/litigation.




PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client registration


PATIENT/CLIENT REGISTRATION AND MANAGEMENT

The function of managing the identification, registration, admission, transfer and

discharge of patients/clients.

See PRE-1930 RECORDS for records created prior to 1930.

2.1.0 Patient/client registration

The management of registers and control records relating to patient/client admission,

identification, transfer, discharge and treatment.

See PHARMACEUTICAL SUPPLY AND ADMINISTRATION for drug registers

maintained on wards.

2.1.1 PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client reg istrati on

Patient/client registration information supporting

unique identification of patients/clients. This may

include patient/client identification or record number

and associated patient/client details (name, date of

birth, sex, address, etc.) that enables unique

identification to support ongoing provision of

treatment, care and services. May also include

associated patient administration details such as health

insurance details, next of kin or guardian, concession

eligibility, etc.

Retain until

administrative or

reference use

ceases (i.e. until

information would

no longer be

required to support

unique identification

and ongoing

provision of care to

registered

patient/client or for

potential legal

action, research,

accountability or

other reference

purposes associated

with the provision

of treatment/care

to the

patient/client), then

destroy

Justification/Remarks: Equivalent to GDA17, 2.1.1 covering Patient Master Index

(PMI), Number register (e.g. card register) or equivalent. No change to current

retention requirements.

Patient/client registration information may be required for potential lifetime of a

patient/client to support identification of patient/clients and information and records

relevant to their history of treatment and care across various services and facilities

within a local health area/district.


Hospital (including Emergency Department) registers

or patient administration system data providing

summary documentation of births, deaths (including

mortuary admissions), patients admitted, presenting,

treated and discharged, length of stay and the nature

Required as State

archives






of treatment and care provided (e.g. admission and

discharge diagnosis, surgical procedures and

operations performed).

Justification/Remarks: These records provide a resource for analysis of the health

status, treatment and care of the population of NSW over time.

Equivalent to GDA17 2.1.2 Disease and operation index. Confirms existing authorised

decision.

Equivalent to GDA17 2.1.4 Admission and discharge registers. Confirms existing

authorised decision.

Equivalent to GDA17 2.1.5 Register of births & labour ward registers. Confirms existing


Equivalent to GDA17 2.1.6 Register of deaths. Confirms existing authorised decision.

Equivalent to GDA17 2.1.7 Emergency Department register. Confirms existing


Equivalent to GDA17 2.1.8. Surgical procedures, Operation or Theatre register.

Confirms existing authorised decision.


Registers or indexes documenting physicians and

medical practitioners with admitting rights and details

of patients attended.

Note: see entry 2.1.2 above for patient admission

registers.

Retain minimum of

15 years after date

of last entry, then

destroy


applying to physicians’ indexes (GDA17, 2.1.3). Confirms existing authorised decision.

Retention period encompasses administrative and potential accountability/legal

requirements.


Registers or summary presenting, treatment and care

data for community health patient/clients and

Ambulance and emergency transport patient/clients.

Note: see also entry 2.1.1 above for patient/client

identification information.

Retain until patient

attains or would

have attained the

age of 25 years or

minimum of 15

years after action

completed,


then destroy


applying to Community health registers (GDA17, 2.1.9). Retention period supports

reference for administrative and potential legal/accountability requirements.

Confirms existing authorised decision re presenting or treatment information for

community health care patients/clients. Certain patient/client registration

information/data should be retained as per 2.1.1 to support ongoing patient/client

identification should patient/client represent.







Registers, summary records, reports, report books and

other ward records documenting the reception,

admission, management, treatment and care of

patient/clients into/on a ward.

Retain minimum of

7 years after last

entry, then destroy


applying to Ward registers (GDA17, 2.1.10) and Ward records (GDA17, 2.5.1).

Retention period encompasses administrative and potential accountability/legal

requirements.


Register of surgically implanted devices or prostheses. Retain minimum of

75 years after

implantation of the

device or

prosthesis, then

destroy

Justification/Remarks: Currently GDA17 requires register of surgically implanted

devices to be retained indefinitely (GDA17, entry 2.1.11). Retention period based on

potential need for records to trace recipients of devices in instances of product recall.


Registers or summary records documenting the

administration of electro-convulsive therapy or

sedation or seclusion of mental health patients.

Retain minimum of

15 years after

action completed,

then destroy


applying to Electro Convulsive Therapy, Sedation and Seclusion registers and Rapid

tranquillisation journals (GDA17, 2.1.12).

Retention period encompasses regulatory and potential accountability/legal

requirements and is in line with the retention of associated clinical files.

Patient/client administration

Administration of arrangements for the provision of treatment, care or services to

patients/clients, includes management of patient property, accounts and finances and

provision of disability equipment.

See PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client

registration for patient registers.

See General Retention and Disposal Authority Administrative records STRATEGIC

MANAGEMENT - Meetings for diaries and appointment books of staff that do not record

patient/client contact.

2.8.1 PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client administration

Records relating to administrative arrangements for

the management of patients/clients. Includes:

• lists and bookings schedules

• routine census or data collection reports or

Retain minimum of


completed, then

destroy




PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client administration


returns

• referrals, requests for services and

recommendations for admission where patient/client

did not attend.

Note: for time periods where admission, discharge,

death, operation or theatre registers do not exist, the

equivalent admission, discharge, etc., lists may

warrant retention as State archives. Contact State

Records to discuss.

Justification/Remarks: This entry will supersede GDA17 entries 1.13.3, 2.2.1, 2.2.2,

2.2.3, 2.2.4, 2.2.5, 2.2.6, 2.4.1 and 2.4.3.

Consistent with current minimum retention requirements applying to patient

admission, transfer, discharge or death lists (GDA17, entry 2.2.1) and

operation/theatre lists, schedules or bookings (GDA17, entry 2.2.2). Increases

retention periods applying to clinical lists, waiting lists and patient related data

collection and census returns/reports/forms (GDA17, entry 2.2.3, 2.2.4, 2.4.1 and

2.4.3) from minimum of 1 year to 2 years. Reduces retention periods for waiting list

audit reports (GDA17, entry 2.2.5) and requests or referrals for services or

recommendation for admission forms where the patient did not attend (GDA17, entry

1.13.3 and 2.2.6) from 3 years to minimum of 2 years.

Retention period enables access in case required for reference, reporting or

accountability purposes.

2.8.2 PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client administration

Records relating to the clinical administration or

management of client/patients documenting contact

not recorded elsewhere e.g. diaries and appointment

books, copies of correspondence, service requests or

referrals where medical record does not incorporate

details, requests for or copies of issued medical

certificates, etc.

Retain minimum of


completed, then

destroy

Justification/Remarks: This entry will supersede GDA17 entries 1.13.3, 1.16.1 and

2.3.1.

Consistent with current minimum retention requirements applying to copies of medical

certificates (GDA17, entry 1.16.1) and work diaries or appointment books (GDA17,

entry 2.3.1). Increases current retention requirements applicable to requests or

referrals (GDA17, entry 1.13.3) from 3 years to minimum of 7 years.

Retention period enables access in case required for reference or accountability

purposes.

2.8.3 PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient property and financ es

Records documenting the management of

patient/client property, accounts and finances.

Includes records which are the primary record of a

patient/client's property, clothing, money and

valuables, authorisations for the payment of monies or

transfer of property e.g. patient election forms, private

patient claim and assignment forms, patient money

and valuables register, property and clothing books,

Retain minimum of


completed, then

destroy




PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient property and finances


accounting records.

Justification/Remarks: This entry will supersede GDA17 entries 7.1.1, 7.1.2, 7.1.4,

7.2.2 and 7.2.3.

Increases current retention requirements applicable to records relating to the

management of patient/client property, accounts and finances (GDA17, entries 7.1.1,

7.1.2, 7.1.4, 7.2.2 and 7.2.3) from minimum of 6 to 7 years.

Retention period is consistent with retention periods applying to primary accountable

records of financial transactions under the General retention and disposal authority:

administrative records (GA28, 7.1.1).

2.8.4 PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient property and financ es

Records relating to the handling of patient/client's

property or finances which are not the primary record

or do not authorise the payment of monies or transfer

of property.

Retain minimum of


completed, then

destroy

Justification/Remarks: This entry will supersede GDA17 entries 7.1.3 and 7.2.2.

Increases current retention requirements applicable to similar records relating to the

management of patient/client property, accounts and finances (GDA17, entries 7.1.3

and 7.2.2) from minimum of 1 to 2 years.

Retention period is consistent with retention periods applying to similar records of

relating to the handling of monies under the General retention and disposal authority:

administrative records (GA28, 7.1.6).

2.8.5 PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Di sability equipment

Records relating to applications for disability

appliances, aids and services e.g. the Program of

Appliances for Disabled People.

Retain minimum of

3 years after last

contact with or use

of the service, then

destroy


applying to applications for disability appliances, aids and services (GDA17, 7.3.1).

2.8.6 PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Di sability equipment

Records relating to the provision and maintenance of

appliances for disabled people.

Retain minimum of


completed, then

destroy


applying to provision and maintenance of appliances for disabled people (GDA17,

7.3.2).




DIAGNOSTIC SERVICES - Imaging and recording services


DIAGNOSTIC SERVICES

The conduct of procedures and tests for the purpose of patient/client diagnosis. This

includes diagnostic imaging, pathology and laboratory services.

Note: Details of requests for diagnostic procedures or tests should be recorded and

retained accordingly as part of the record of patient treatment and care, e.g. as part of

the progress notes or a copy of any request is maintained as part of the patient file. The

original or a copy of any diagnostic report should also be maintained as part of the

patient record and retained accordingly.

See PATIENT/CLIENT TREATMENT AND CARE for diagnostic procedure or test

requests and reports of diagnostic results which form part of the record of patient

treatment and care.

3.0.0 Imaging and recording services

Diagnostic imaging and recording services. This includes diagnostic radiology,

tomography, nuclear medicine, ultrasound, magnetic resonance imaging and related

diagnostic digital imaging procedures.

3.1.1 DIAGNOSTIC SERVICES - Imaging and record ing servi ces

Diagnostic service copies of requests for and reports or

findings of diagnostic procedures, tests or services.

Retain minimum of

3 years after

provision of service

or date of report,

then destroy

Justification/Remarks: Retention period is consistent with current minimum

retention requirements applying to diagnostic service copies of requests for imaging

diagnostic services (GDA17, 3.1.1) and diagnostic reports or findings maintained by

imaging diagnostic services (GDA17, 3.2.2).

Retention period encompasses administrative and accountability requirements based

on NSW Health audit cycle. Also encompasses Department of Health (Cth) Medical

Benefits Schedule requirements for retention of diagnostic imaging requests for a

period of least 18 months from the day on which the service was rendered.

Details of diagnostic requests and a copy or the original of any diagnostic report are

retained for longer time periods as part of patient/client record.


Recordings of diagnostic procedures. Includes:

radiology (X-Rays) images

recordings of electroencephalograms,

electrocardiograms, electromyograms,

cardiotocograms etc

ultra-sound images

Computed Tomography (CT) scans

Magnetic Resonance Images (MRI)

photographs, videotapes

Release to patient

upon request if not

required for

possible future

treatment or other

reasons, such as

litigation, or retain

a minimum of 7

years after last

attendance for

diagnostic

procedure, then




DIAGNOSTIC SERVICES - Imaging and recording services


measurements, gradings, readings and other

data e.g. data from sleep studies.

Note: reports of the results of tests, including the

reporting of abnormalities, are required to be retained

as per the patient record.

Note: images may need to be retained for longer

periods where an abnormality is detected, a minor is

involved, or where a specific medical condition

warrants longer retention.

destroy

TB (tuberculosis)

chest X-Ray:

Retain for potential

lifetime of patient

(85 years from date

of birth if date of

death unknown),

then destroy

Justification/Remarks: Retention period based on potential need for reference for

legal purposes (legal action, compensation claims, etc.). Removal of requirement to

retain at least until patient reaches age 25. A copy of any associated diagnostic report

should be retained as part of the main patient record for a minimum period of at least

7 years (or longer depending on the category of patient and treatment and care

provided) after last access by or on behalf of the patient or until patient attains age 25.

Increases retention requirements for diagnostic graphical recordings where there is no

abnormality detected and results are noted in the patient's record (GDA17, 3.3.3) from

retain until administrative use ceases to minimum of 7 years after attendance.

Increases retention requirements for TB chest X-Rays from 7 years after attendance

or until age 25 to retain for potential life of the patient - 85 years from date of

birth if date of death unknown.

Longer retention period for TB chest X-Rays based on recommendation from Ministry of

Health (Office of the Chief Health Officer, Director Communicable Diseases, Health

Protection NSW).


Registers or associated control records maintained for

the purposes of identifying or locating diagnostic

recordings and reports.

Note: The registers should be retained for as long as

they might conceivably be required for the purposes of

locating a recording, or, where the records contain the

details of the disposal of individual recordings,

accounting for the disposal of the recording.

Retain until

administrative or

reference use

ceases, then

destroy


diagnostic service registers or control records (GDA17, 3.4.1). Disposal action

amended to until administrative or reference use ceases.

4.0.0 Pathology and laboratory services

Medical pathology and laboratory diagnostic services. This includes anatomical pathology,

cytology, haematology, clinical chemistry/clinical pathology, blood banks, immunology,

microbiology and genetics.

Note: Bodily specimens, samples or materials are not considered to be records within

the meaning of the State Records Act and are not covered by this authority. They should

be managed, retained and disposed of in accordance with relevant legislation or




DIAGNOSTIC SERVICES - Pathology and laboratory services


standards and guidelines issued by an appropriate body e.g. National Pathology

Accreditation Advisory Council (NPAAC).

4.1.1 DIAGNOSTIC SERVICES - Pathol ogy and laborat ory servi ces

Diagnostic service copies of requests or referrals for

and reports or findings of diagnostic procedures, tests

or services. Includes associated declarations, consents,

etc.

Retain in

accordance with the

relevant legislative

requirements

and/or national

standards and

guidelines (for

example standards

and guidelines

issued by the

National Pathology

Accreditation

Advisory Council or

its successor

agency/ies)

Justification/Remarks: Current retention periods under GDA17 are consistent with

requirements applying under legislative, regulatory and National Pathology

Accreditation Advisory Council (NPAAC) standards and guidelines at the time of its

approval (2004). Legislation, regulations and NPAAC standards and guidelines may be

updated from time to time and requirements can change. To avoid inconsistency

between retention requirements identified by legislation or industry standards as they

are revised and updated and the requirements of the State Records Act the disposal

action has been amended to allow for retention and disposal in accordance with current

applicable requirements as outlined in legislation or quality standards, etc.


Records relating to the tracking or monitoring of

testing completion and the management or control of

received or collected bodily parts or specimens.

Includes registers and other associated control records

maintained for the purposes of identifying or locating

specimens.

Note: Retention periods should be in accordance with

the minimum retention periods required for the types

of specimens recorded in the register, and where these

records contain the details of the disposal of individual

specimens, the records should be retained for as long

as they might conceivably be required for the purposes

of accounting for the disposal of the specimen.

Retain until

administrative or

reference use

ceases, then

destroy


diagnostic service registers or control records (GDA17, 4.3.2). Disposal action

amended to until administrative or reference use ceases.


Records of blood, blood product and semen donation

and supply. Includes donor records and consents and

records documenting the supply of products.

Retain in

accordance with the





DIAGNOSTIC SERVICES - Pathology and laboratory services


requirements

and/or national

standards and

guidelines (for

example standards

and guidelines

issued by the

National Pathology

Accreditation

Advisory Council or

its successor

agency/ies)











Records relating to:

quality control and assurance (certification,

implementation and audit of processes and

services)

the maintenance and servicing of equipment

used for diagnostic or testing purposes

methodologies and standard procedures for the

conduct of diagnostic tests and procedures.

Retain in

accordance with the


requirements

and/or national

standards and

guidelines (for

example standards

and guidelines

issued by the

National Pathology

Accreditation

Advisory Council or

its successor

agency/ies)













PHARMACEUTICAL SUPPLY AND ADMINISTRATION - Dispensing and supply


PHARMACEUTICAL SUPPLY AND ADMINISTRATION

Management of the supply, administration, dispensing and use of pharmaceuticals,

encompassing drugs, poisons and other chemical substances

See PATIENT/CLIENT TREATMENT AND CARE for patient medication charts, incident

reports and Consent forms for special access scheme drugs

5.1.0 Dispensing and supply

The supply and dispensing of pharmaceuticals.

5.1.1 PHARMACEUTICAL SU PPL Y AN D AD MINISTRATION - Di spensing and supply

Records relating to the supply, dispensing and

inventory of pharmaceuticals. This includes requisitions

and orders for pharmaceutical products or substances,

prescriptions (other than for highly specialised drugs),

records of medication chart orders, records of supply

other than on prescription, and receipts/records of

delivery.

This includes requisitions and orders for

pharmaceutical products or substances, prescriptions

(other than for Highly Specialised Drugs – see section

5.1.3), records of supply on medication chart orders,

records of supply on prescription, records of supply

other than on prescription or medication chart order,

and receipts/records of delivery.

Retain minimum of


completed, then

destroy


applying to records relating to the supply and dispensation of pharmaceuticals (GDA17,

5.1.1) and records relating to pharmaceutical stock and inventory (GDA17, 5.1.4).

Retention periods are based on administrative, regulatory, accountability and legal

requirements.

The Poisons and Therapeutic Goods Act 1966 and the Poisons and Therapeutic Goods

Regulation 2008 require certain records to be created and maintained by those

responsible for the control, storage and supply of certain substances and drugs of

addiction. Clause 176 of the Regulation establishes that all records required to be

created and maintained under the Regulation are required to be maintained on the

premises for a 2 year retention period. The minimum retention periods for these

records incorporate current minimum retention requirements in accordance with the

Regulation. The National Health Act 1953 (C'wth) also regulates the retention of

prescriptions subsidised under the Commonwealth Pharmaceutical Benefits Scheme.


Records relating to the procurement, supply,

dispensing, administration, audit of drugs of addiction.

Includes:

drug registers required to be maintained by

regulation (e.g. schedule 8 medications, drugs

of addiction, etc.) and for any other medicines

as required by local policy (e.g. Schedule 4

Retain minimum of

7 years after date

of entry or action

completed, then

destroy




PHARMACEUTICAL SUPPLY AND ADMINISTRATION - Dispensing and supply


Appendix D medications) held in the pharmacy,

ward or other departments

applications to prescribe drugs of addiction as

part of a treatment program and associated

medical reports, authorities, treatment

proposals, correspondence, etc.


applying to drug registers (GDA17, 5.1.3) and records relating to applications to

prescribe drugs of addiction as part of a treatment program (GDA17, 5.1.8).

It is NSW Health policy to retain these types of records for longer than the 2 year

period required by the Poisons and Therapeutic Goods Regulation 2008 for the

purposes of possible future investigations. Retention period re applications to prescribe

drugs of addiction consistent with recommendation of Ministry of Health

Pharmaceutical Services Unit.


Records relating to the supply of medications under

Highly Specialised Drugs programs. Includes

prescriptions and declaration forms signed by the

prescriber.

Retain minimum of

7 years after date

of receipt, then

destroy


applying to records relating to the supply of medications under highly specialised drugs

programs (GDA17, 5.1.5).

Retention period was based on NSW Health Circular 2000/83 Section 100 highly

specialised drugs program guidelines - now superseded by NSW Health Policy Directive

PD2013_043 Medication Handling in NSW Public Health Facilities.


Therapeutic Goods Administration (TGA) application

and notification forms (for example, prescribing of

Special Access Scheme medications and Clinical Trial

drugs).

Retain minimum of


completed, then

destroy


applying to records relating to TGA application forms (GDA17, 5.1.7).

Retention period based on recommendation of Department of Health Pharmaceutical

Services Section who administer the scheme.


Records relating to the reporting of lost or stolen drugs

or drug registers.

Retain minimum of

10 years after

action completed,

then destroy


applying to records relating to the reporting of lost or stolen drugs (GDA17, 5.1.9).

Retention periods are based on accountability and potential legal requirements.




NOTIFICATIONS - Health reporting


NOTIFICATIONS

Notification and reporting to prescribed bodies or authorities in accordance with statutory

or other requirements.

See PATIENT/CLIENT TREATMENT AND CARE for service provider records of the

notification or reporting of patient/client conditions, instances, episodes, etc., e.g. birth

and death notifications or certificates, reports of notifiable diseases, mandatory reporting

of suspected criminal activity (e.g. abuse), etc.

6.2.0 Health reporting

Notification and reporting to prescribed bodies regarding patient/client medical

conditions, instances, episodes, etc.

6.2.2 NOTIFICATIONS - H ealth reporting

Reports of an incidence of a notifiable disease received

by Public Health Units.

Note: Duplicate notifications received subsequent to

the initial notification can be disposed of when no

longer required for administrative or reference

purposes

Retain minimum of


completed, then

destroy


applying to records of initial reports of notifiable diseases received by a Public Health

Unit (GDA17, 6.2.2). Also consistent with retention periods applying to Public Health

Unit records of follow up activities in response to receipt of a notification (General

retention and disposal authority: public health sector - administrative records, GDA21,

entry 12.11.1).

Retention periods are based on regulatory, accountability and legal requirements.

Ministry retains the registers of notifiable diseases as State archives (NSW Health

functional authority DA25 5.5.1) and the notifications for 10 years (DA25 5.5.2).




RESEARCH MANAGEMENT - Research projects, trials or studies


RESEARCH MANAGEMENT

Management of research, trials or studies, etc.

Note: This does not apply to records created and maintained by Committees formed to

oversight the conduct of research activities (e.g. Research Ethics Committees)

8.1.0 Research projects, trials or studies

The conduct of clinical and non-clinical research, trials or studies, etc.

8.1.1 RESEARCH MANAGEMENT - Research projects, tri als or studies

Records relating to the conduct of clinical research.

This includes records or documentation relating to the

recruitment and consent of research participants,

data/records/information access requests and

approvals, the collection and analysis of data,

preliminary findings, surveys, reporting and results.

Retain minimum of

15 years after date

of publication or

completion of the

research or

termination of the

study, then destroy


applying to records of clinical research (GDA17, 8.1.1) and to requests to access

records for approved clinical research (GDA17, 8.1.3).

Consistent with minimum retention recommendations of the Australian Code for the

Responsible Conduct of Research.


Records relating to the conduct of:

clinical audits for the purposes of evidence

based quality management (e.g. an audit of the

outcome of pain management treatment)

non clinical research, or

research not involving humans.

This includes records of any associated consents or

data/records/information access requests and

approvals, the collection and analysis of data, conduct

of surveys, reports of findings or results.

Retain minimum of

5 years after date

of publication or

completion of the

research or

termination of the

study, then destroy


applying to records of clinical audits (GDA17, 1.15.1), non clinical research or research

not involving humans (GDA17, 8.1.2) and to requests to access records for research

(GDA17, 8.1.4).

Consistent with minimum retention recommendations of the Australian Code for the

Responsible Conduct of Research.


Records of requests relating to projects where the

research does not proceed.

Retain minimum of


completed, then

destroy

Justification/Remarks: Consistent with current requirements applying to research




RESEARCH MANAGEMENT - Research projects, trials or studies


project requests where the research does not proceed (GDA17, 8.1.5).

Retention periods encompasses potential reference for audit and accountability

purposes.




PRE-1930 PATIENT/CLIENT RECORDS & COLLECTIONS OR SAMPLES OF PATIENT/CLIENT

RECORDS


PRE-1930 PATIENT/CLIENT RECORDS & COLLECTIONS OR SAMPLES OF PATIENT/CLIENT RECORDS

Patient/client records created prior to 1930 and collections or samples of patient records

of significance.

10.1.0 PRE-1930 PATIENT/CLIENT RECORDS & CO LLECTIONS OR SA MPLES OF PATIENT/C LIENT RECORDS

Patient/client records created wholly or in part prior to

1930. This includes records identified in the previous

sections created wholly or in part prior to 1930.

Required as State

archives

Justification/Remarks: Consistent with current requirements (GDA17, entry 10.1.0).

The 1930 date corresponds with the introduction of the Public Hospitals Act 1929. The

Act established the Health Commission and a state wide system for the regulation and

quality assurance of hospital services. This will ensure the retention of records

documenting the operation of services and medical practices prior to their more

effective regulation by government.

10.2.0 PRE-1930 PATIENT/CLIENT RECORDS & CO LLECTIONS OR SA MPLES OF PATIENT/C LIENT RECORDS

Collections or samples of patient records identified as

being of continuing value for medical or social research

purposes.

Required as State

archives

Justification/Remarks: Consistent with current provisions of GDA17, entry 1.11.1.

These provisions enable the transfer of significant, exemplary or unique collections of

patient records that individual services may identify amongst their holdings as

warranting ongoing retention as State archives. This may be because the service has

taken a leading role in the development and delivery of new or specialised treatments

for a particular illness or condition or because the records:

illustrate or provide comparative insight into the provision of services to

particular community groups

illustrate or provide comparative insight into aspects of treatment, care and the

delivery of services over time

document significant achievements in research or break throughs in research or

relate to research of major national or international significance, interest or

controversy

document significant outbreaks of disease that represented major public health

risks and their impact

document critical points of change or developments in the treatment or

management of a particular type of condition, illness or disease

relate to the diagnosis, management, treatment of or research into particularly rare

diseases or conditions and would significantly enhance and contribute to the existing

body of knowledge of these diseases or conditions.

general retention and disposal authority: public health ... · general retention and disposal...

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