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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

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