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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 of New South Wales through the State Archives and Records Authority of New South Wales 2016. Permission must be received from the State Archives and Records Authority for use.
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
State Archives and Records Authority of New South Wales 2 of 32
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.
State Archives and Records Authority of New South Wales 3 of 32
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 -
patient/client records
List of Functions and Activities covered
State Archives and Records Authority of New South Wales 4 of 32
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
State Archives and Records Authority of New South Wales 5 of 32
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 -
patient/client records
No. Description of records Disposal action
State Archives and Records Authority of New South Wales 6 of 32
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.
1.1.2 PATIENT/CLIENT TREATMENT AN D CARE - H ospital and em ergency care
Records documenting the treatment and care of
admitted patients of Group B hospitals and services.
Retain minimum of
10 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
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT TREATMENT AND CARE - Hospital and emergency care
State Archives and Records Authority of New South Wales 7 of 32
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.
1.1.3 PATIENT/CLIENT TREATMENT AN D CARE - H ospital and em ergency care
Records documenting the treatment and care of
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
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 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.
1.1.4 PATIENT/CLIENT TREATMENT AN D CARE - H ospital and em ergency care
Records documenting the treatment and care of
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,
whichever is longer,
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.
1.1.5 PATIENT/CLIENT TREATMENT AN D CARE - H ospital and em ergency care
Records documenting the receipt of and action taken
in response to emergency calls or communications.
Retain minimum of 7
years after action
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT TREATMENT AND CARE - Community based health care
State Archives and Records Authority of New South Wales 8 of 32
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,
whichever is longer,
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
the age of 25 years,
then destroy
Justification/Remarks: Consistent with current minimum retention requirements
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.
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT TREATMENT AND CARE - Community based health care
State Archives and Records Authority of New South Wales 9 of 32
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
Justification/Remarks: Consistent with current minimum retention requirements
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,
whichever is longer,
then destroy
Justification/Remarks: Consistent with current minimum retention requirements
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.
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT TREATMENT AND CARE - Obstetric/maternal health care
State Archives and Records Authority of New South Wales 10 of 32
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.
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT TREATMENT AND CARE - Psychiatric and mental health care
State Archives and Records Authority of New South Wales 11 of 32
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
Records documenting the treatment and care of
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,
whichever is longer,
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.
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT TREATMENT AND CARE - Genetic or inherited disorders
State Archives and Records Authority of New South Wales 12 of 32
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
Justification/Remarks: Consistent with current retention requirements applying to
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)
Records documenting the treatment and care of
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
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT TREATMENT AND CARE - Sexual assault patients
State Archives and Records Authority of New South Wales 13 of 32
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
Records documenting the treatment and care of
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,
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT TREATMENT AND CARE - Physical abuse and neglect
State Archives and Records Authority of New South Wales 14 of 32
whichever is longer,
then destroy
Justification/Remarks: Consistent with current minimum retention requirements
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,
whichever is longer,
then destroy
Justification/Remarks: Consistent with current minimum retention requirements
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,
whichever is longer,
then destroy
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT TREATMENT AND CARE - Complaints and incident management
State Archives and Records Authority of New South Wales 15 of 32
Justification/Remarks: This entry will supersede GDA17 entry 1.10.1.
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
Justification/Remarks: Consistent with current minimum retention requirements
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,
whichever is longer,
then destroy
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT TREATMENT AND CARE - Surgical procedures and instruments
State Archives and Records Authority of New South Wales 16 of 32
Justification/Remarks: This entry will supersede GDA17 entry 1.14.3.
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
Justification/Remarks: Consistent with current minimum retention requirements
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
Justification/Remarks: Consistent with current minimum retention requirements
applying to originals and duplicates of accountable items (GDA17, 1.18.1).
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT TREATMENT AND CARE - Surgical procedures and instruments
State Archives and Records Authority of New South Wales 17 of 32
Retention period encompasses potential legal enquiries/litigation.
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client registration
State Archives and Records Authority of New South Wales 18 of 32
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.
2.1.2 PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client reg istrati on
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
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client registration
State Archives and Records Authority of New South Wales 19 of 32
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
authorised decision.
Equivalent to GDA17 2.1.6 Register of deaths. Confirms existing authorised decision.
Equivalent to GDA17 2.1.7 Emergency Department register. Confirms existing
authorised decision.
Equivalent to GDA17 2.1.8. Surgical procedures, Operation or Theatre register.
Confirms existing authorised decision.
2.1.3 PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client reg istrati on
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
Justification/Remarks: Consistent with current minimum retention requirements
applying to physicians’ indexes (GDA17, 2.1.3). Confirms existing authorised decision.
Retention period encompasses administrative and potential accountability/legal
requirements.
2.1.9 PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client reg istrati on
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,
whichever is longer,
then destroy
Justification/Remarks: Consistent with current minimum retention requirements
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.
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client registration
State Archives and Records Authority of New South Wales 20 of 32
2.1.10 PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client reg istrati on
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
Justification/Remarks: Consistent with current minimum retention requirements
applying to Ward registers (GDA17, 2.1.10) and Ward records (GDA17, 2.5.1).
Retention period encompasses administrative and potential accountability/legal
requirements.
2.1.11 PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client reg istrati on
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.
2.1.12 PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client reg istrati on
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
Justification/Remarks: Consistent with current minimum retention requirements
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
2 years after action
completed, then
destroy
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client administration
State Archives and Records Authority of New South Wales 21 of 32
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
7 years after action
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
7 years after action
completed, then
destroy
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient property and finances
State Archives and Records Authority of New South Wales 22 of 32
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
2 years after action
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
Justification/Remarks: Consistent with current minimum retention requirements
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
5 years after action
completed, then
destroy
Justification/Remarks: Consistent with current minimum retention requirements
applying to provision and maintenance of appliances for disabled people (GDA17,
7.3.2).
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
DIAGNOSTIC SERVICES - Imaging and recording services
State Archives and Records Authority of New South Wales 23 of 32
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.
3.3.1 DIAGNOSTIC SERVICES - Imaging and record ing servi ces
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
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
DIAGNOSTIC SERVICES - Imaging and recording services
State Archives and Records Authority of New South Wales 24 of 32
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).
3.4.1 DIAGNOSTIC SERVICES - Imaging and record ing servi ces
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
Justification/Remarks: Consistent with current retention requirements applying to
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
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
DIAGNOSTIC SERVICES - Pathology and laboratory services
State Archives and Records Authority of New South Wales 25 of 32
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.
4.3.2 DIAGNOSTIC SERVICES - Pathol ogy and laborat ory servi ces
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
Justification/Remarks: Consistent with current retention requirements applying to
diagnostic service registers or control records (GDA17, 4.3.2). Disposal action
amended to until administrative or reference use ceases.
4.4.1 DIAGNOSTIC SERVICES - Pathol ogy and laborat ory servi ces
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
relevant legislative
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
DIAGNOSTIC SERVICES - Pathology and laboratory services
State Archives and Records Authority of New South Wales 26 of 32
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.
4.6.1 DIAGNOSTIC SERVICES - Pathol ogy and laborat ory servi ces
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
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.
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PHARMACEUTICAL SUPPLY AND ADMINISTRATION - Dispensing and supply
State Archives and Records Authority of New South Wales 27 of 32
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
2 years after action
completed, then
destroy
Justification/Remarks: Consistent with current minimum retention requirements
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.
5.1.3 PHARMACEUTICAL SU PPL Y AN D AD MINISTRATION - Di spensing and supply
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
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PHARMACEUTICAL SUPPLY AND ADMINISTRATION - Dispensing and supply
State Archives and Records Authority of New South Wales 28 of 32
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.
Justification/Remarks: Consistent with current minimum retention requirements
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.
5.1.5 PHARMACEUTICAL SU PPL Y AN D AD MINISTRATION - Di spensing and supply
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
Justification/Remarks: Consistent with current minimum retention requirements
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.
5.1.7 PHARMACEUTICAL SU PPL Y AN D AD MINISTRATION - Di spensing and supply
Therapeutic Goods Administration (TGA) application
and notification forms (for example, prescribing of
Special Access Scheme medications and Clinical Trial
drugs).
Retain minimum of
7 years after action
completed, then
destroy
Justification/Remarks: Consistent with current minimum retention requirements
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.
5.1.9 PHARMACEUTICAL SU PPL Y AN D AD MINISTRATION - Di spensing and supply
Records relating to the reporting of lost or stolen drugs
or drug registers.
Retain minimum of
10 years after
action completed,
then destroy
Justification/Remarks: Consistent with current minimum retention requirements
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.
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
NOTIFICATIONS - Health reporting
State Archives and Records Authority of New South Wales 29 of 32
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
7 years after action
completed, then
destroy
Justification/Remarks: Consistent with current minimum retention requirements
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).
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
RESEARCH MANAGEMENT - Research projects, trials or studies
State Archives and Records Authority of New South Wales 30 of 32
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
Justification/Remarks: Consistent with current minimum retention requirements
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.
8.1.2 RESEARCH MANAGEMENT - Research projects, tri als or studies
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
Justification/Remarks: Consistent with current minimum retention requirements
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.
8.1.5 RESEARCH MANAGEMENT - Research projects, tri als or studies
Records of requests relating to projects where the
research does not proceed.
Retain minimum of
3 years after action
completed, then
destroy
Justification/Remarks: Consistent with current requirements applying to research
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
RESEARCH MANAGEMENT - Research projects, trials or studies
State Archives and Records Authority of New South Wales 31 of 32
project requests where the research does not proceed (GDA17, 8.1.5).
Retention periods encompasses potential reference for audit and accountability
purposes.
General retention and disposal authority: public health services
Patient/client records
No. Description of records Disposal action
PRE-1930 PATIENT/CLIENT RECORDS & COLLECTIONS OR SAMPLES OF PATIENT/CLIENT
RECORDS
State Archives and Records Authority of New South Wales 32 of 32
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.