General Retention and Disposal Authority: public health services – patient/client records
GDA17 to revised draft Linking Table
reference / Comments /
PATIENT/CLIENT TREATMENT AND CARE / PATIENT/CLIENT TREATMENT AND CARE
GDA17 1.1.1 / Hospital care
Group A hospitals / Hospital and emergency care
1.1.1 / No change to scope of coverage or retention requirements.
GDA17 1.1.2 / Hospital and emergency care
Group B hospitals and services / Hospital and emergency care
1.1.2 / No change to scope of coverage or retention requirements.
GDA17 1.1.3 / Hospital care
Patients attending or presenting at emergency or out-patient clinics that are not admitted as patients / Hospital and emergency care
1.1.3 / No change to scope of coverage or retention requirements.
Hospital and emergency care
1.1.4
Ambulance, emergency and non emergency transport services / New entry to cover ambulance, emergency and non-emergency transport patients.
Hospital and emergency care
1.1.5
Receipt and response to emergency calls or communications / New entry to cover recordings of emergency calls, communications, vehicle dispatch, etc.
GDA17 1.2.1 / Community health care
Client health records / Community based health care
1.2.1 / No change to retention requirements excepting TB services (chest clinics) client health records where retention period increased to minimum of 15 years after last attendance or contact.
Scope of coverage amended to encompass immunisation and child/baby/school screening records.
GDA17 1.2.2 / Community health care
Immunisation records - no adverse or other reaction / Community based health care
1.2.1 / Increase in retention period for records relating to the treatment of minors until age of 25.
GDA17 1.2.3 / Community health care
Immunisation records – adverse reaction / Community based health care
1.2.1 / No change to retention requirements.
GDA17 1.2.4 / Community health care
Child/baby health care screening - no abnormality detected / Community based health care
1.2.1 / Increase in retention period from until age of 6 to until age of 25.
GDA17 1.2.5 / Community health care
Child/baby health care screening - abnormality detected / Community based health care
1.2.1 / No change to retention requirements.
GDA17 1.2.6 / Community health care
School screening records – no abnormality detected / Community based health care
1.2.1 / Increase in retention period until age of 25.
GDA17 1.2.7 / Community health care
School screening records - abnormality detected / Community based health care
1.2.1 / No change to retention requirements.
GDA17 1.2.8 / Community health care
MERIT program criminal histories / Community based health care
1.2.8 / No change to scope of coverage or retention requirements.
GDA17 1.3.1 / Oral (dental) health care / Oral (dental) health care
1.3.1 / No change to retention requirements. Scope amended to encompass consent forms.
GDA17 1.3.2 / Oral (dental) health care
School dental consent forms / Oral (dental) health care
1.3.1 / Increase in retention period from 2 years to minimum of 7 years or until age of 25.
GDA17 1.4.1 / Obstetric/maternal health care
Records documenting birth episodes / Obstetric/maternal health care
1.4.1 / Retention requirements changed from indefinite retention to retain minimum of 30 years after date of birth. Description amended to provide more specific detail of scope of records covered.
GDA17 1.4.2 / Obstetric/maternal health care
Social work records relating to instances of arrangements for adoptions / Obstetric/maternal health care
1.4.2 / No change to retention requirements. Description amended so scope not limited to social work records only but encompasses more broadly records documenting adoption arrangements that proceed.
GDA17 1.5.1 / Psychiatric and mental health care
Pre 1960 records Crown operated or Schedule 5 hospitals / Psychiatric and mental health care
1.5.1 / No change to retention requirements.
GDA17 1.5.2 / Psychiatric and mental health care
Patients/clients receiving psychiatric treatment and care and/or treatment and care (including community health care) under the Mental Health Act. / Psychiatric and mental health care
1.5.3 / Increase in retention period from 15 years after last attendance, [etc.], or until age 25 to minimum of 25 years after last attendance, contact or access by or on behalf of the patient or until patient attains age 43 (i.e. 25 years after age 18), whichever is longer. No change to scope of coverage.
GDA17 1.6.1 / Genetic or inherited disorders - diagnosis / Genetic or inherited disorders
1.6.1 / Scope of coverage amended to limit to records maintained by specialist genetics units only. No change to retention requirements.
GDA17 1.6.2 / Genetic or inherited disorders - management / See Hospital and Emergency Care and Community Health Care / Entry replaced by see reference. Records relating to provision of treatment and care to be retained in accordance with the requirements applying to the type of patient/client records they comprise. No change to retention requirements.
GDA17 1.7.1 / Assisted Reproductive Technology (ART)
Where a child is born or a pregnancy achieved / Assisted Reproductive Technology (ART)
1.7.3 / Retention requirements changed from retain 75 years from DOB to 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, whichever is longer. Scope amended to encompass records irrespective of whether or not a pregnancy achieved.
GDA17 1.7.2 / Assisted Reproductive Technology (ART)
Other ART records / Assisted Reproductive Technology (ART)
1.7.3 / To avoid potential inconsistency between retention requirements identified by ART legislation and the State Records Act the disposal action amended to allow for retention and disposal in accordance with ART legislative requirements. Retention requirements for certain records may increase in compliance with ART legislative requirements.
GDA17 1.8.1 / Sexual assault patients
Records relating to instances of sexual assault / Sexual assault patients
1.8.1 / No change to scope of coverage or retention requirements.
GDA17 1.9.1 / PANOC Special Services
Client records of PANOC Specialist Services / Physical abuse and neglect
1.9.1 / No change to retention requirements. Description amended so not limited to PANOC specialist services but applies more broadly to abuse and neglect of vulnerable persons e.g. children, elderly, disabled or persons in care, where instances of suspected abuse and neglect are subject to mandatory reporting.
GDA17 1.10.1 / Radiotherapy treatment
Records documenting radiation dose delivery / Radiotherapy treatment
1.10.2 / Increase in retention period from 10 to minimum of 15 years after age of 70, date of death or last attendance, whichever is longer. No change to scope of coverage.
GDA17 1.11.0 / Electronic health records (1.11.1 – 1.11.3) / Entry for electronic health records removed. Records in electronic format should be retained and disposed of as per the category/type of record they comprise/purpose for which they were created/used.
No change to retention requirements.
GDA17 1.12.1 / Collections or samples of patient records of continuing value for medical or social research purposes / 10.2.0 Collections or samples of patient records of continuing value for medical or social research purposes / No change to scope of coverage or retention requirements.
GDA17 1.13.1 / Correspondence
Routine correspondence with individual patients/clients or others on behalf of patients/ clients and records documenting telephone contact and any medical advice given / Records to be retained in accordance with the requirements applying to the type of patient/client records they comprise i.e. hospital or community health care.
Retention requirements for certain records may increase depending on category of facility & treatment/care provided.
GDA17 1.13.2 / Correspondence
Correspondence logs or registers / See General retention and disposal authority: administrative records (INFORMATION MANAGEMENT – Control)
GDA17 1.13.3 / Copies of requests or referrals for other services where patient did not attend / PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client administration
2.8.1 / Retention period reduced from 3 to minimum of 2 years.
See 2.8.2 for service requests or referrals where medical record does not incorporate details.
GDA17 1.14.1 / Legal matters and incident management Issues, claims or case matters of significance (precedent, change in policy, controversy) / See General retention and disposal authority: administrative records (LEGAL SERVICES – Litigation)
GDA17 1.14.2 / Legal matters and incident management Other issues, claims or case matters involving legal action / See General retention and disposal authority: administrative records (LEGAL SERVICES – Litigation)
GDA17 1.14.3 / Legal matters and incident management Complaints and incidents not involving legal action / Complaints and incident management
1.14.7 / Increase in retention period for complaints or incidents involving minors until age of 25. Scope amended so not limited to complaints or incidents not involving legal action. Records of any legal action arising from a complaint or incident are covered by the General retention and disposal authority: administrative records.
GDA17 1.14.4 / Legal matters and incident management
Subpoenas and discovery orders relating to legal action involving the health service or facility / See General retention and disposal authority: administrative records (LEGAL SERVICES – Litigation) / For coverage of records see General retention and disposal authority: administrative records (Legal services – Litigation). No change to retention requirements unless significant/precedent setting (State archives).
GDA17 1.14.5 / Legal matters and incident management
Subpoenas and discovery orders relating to litigation not directly involving the health service or facility / See General retention and disposal authority: administrative records (LEGAL SERVICES – Litigation) / For coverage of records see General retention and disposal authority: administrative records (Legal services – Litigation). No change to retention requirements.
GDA17 1.14.6 / Legal matters and incident management
Register of patient injuries / Complaints and incident management
1.14.6 / No change to retention requirements. Scope amended to include registers or equivalent summary records of patient/client complaints, injuries or incidents.
GDA17 1.15.1 / Clinical audits
Clinical audits conducted for the purposes of evidence based quality management / RESEARCH MANAGEMENT – Research projects
8.1.2 / No change to retention requirements.
GDA17 1.16.1 / Medical certificates
Copies of issued medical certificates / PATIENT/CLIENT REGISTRATION AND MANAGEMENT - Patient/client administration
2.8.2 / No change to retention requirements.
GDA17 1.17.1 / Sterilisation records
Sterilisation printouts / Surgical procedures and instruments
1.17.1 / No change in retention requirements. Trigger for calculating retention period changed from date of printout to action completed.
GDA17 1.17.2 / Sterilisation records
Sterilisation registers and log books / Surgical procedures and instruments
1.17.1 / No change in retention requirements. Trigger for calculating retention period changed from last entry to action completed.
GDA17 1.18.1 / Surgical procedures – accountable items / Surgical procedures and sterilisation of equipment
1.18.1 / No change to retention requirements for duplicates. Disposal action amended to incorporate requirements for originals to be retained as per patient/client record.
GDA17 reference / Function/Activity/Records / Draft
reference / Comments /
PATIENT/CLIENT REGISTRATION AND IDENTIFICATION / PATIENT/CLIENT REGISTRATION AND MANAGEMENT
GDA17 2.1.1 / Registers and indexes
Patient Master Index (PMI), Number register (eg card register) or equivalent / Patient/client registration
2.1.1
Patient/client registration information supporting unique identification of patients/clients. / No change to retention requirements. Description amended. Disposal action amended to include guiding information with respect to determination of cessation of administrative and reference use.
GDA17 2.1.2 / Registers and indexes
Disease and operation index / Patient/client registration
2.1.2
Patient registration or administration information providing summary details of births, deaths, admissions, etc. / No change to retention requirements. Description amended to incorporate coverage for various patient registration and summary information to be retained as State archives, irrespective of format.
GDA17 2.1.3 / Registers and indexes
Physicians index / Patient/client registration
2.1.3
Registers or indexes documenting physicians and medical practitioners with admitting rights and details of patients attended / No change to retention requirements. description amended.
GDA17 2.1.4 / Registers and indexes
Admission and discharge registers / Patient/client registration
2.1.2
Patient registration or administration information providing summary details of births, deaths, admissions, etc. / No change to retention requirements.
GDA17 2.1.5 / Registers and indexes
Register of births / Patient/client registration
2.1.2
Patient registration or administration information providing summary details of births, deaths, admissions, etc. / No change to retention requirements.
GDA17 2.1.6 / Registers and indexes
Death register / Patient/client registration
2.1.2
Patient registration or administration information providing summary details of births, deaths, admissions, etc. (including mortuary admissions) / No change to retention requirements.
GDA17 2.1.7 / Registers and indexes
Emergency Department register / Patient/client registration
2.1.2
Patient registration or administration information providing summary details of births, deaths, admissions, etc. / No change to retention requirements.
GDA17 2.1.8 / Registers and indexes
Surgical procedures, Operation or Theatre register / Patient/client registration
2.1.2
Patient registration or administration information providing summary details of births, deaths, admissions, etc. / No change to retention requirements.
GDA17 2.1.9 / Registers and indexes
Community health registers / Patient/client registration
2.1.9
Registers or summary presenting, treatment and care data for community health patient/clients and emergency transport patient/clients. / No change to retention requirements however regard should be had to the requirements of 2.1.1 re retention of patient/client unique identification data/information.
Scope amended to encompass registers, summary data for Ambulance and emergency transport patient/clients.
GDA17 2.1.10 / Registers and indexes
Ward register / Patient/client registration
2.1.10 / No change to retention requirements. Description amended.
GDA17 2.1.11 / Registers and indexes
Register of surgically implanted devices / Patient/client registration
2.1.11 / Retention requirements changed from indefinite retention to retain minimum of 75 years after implantation of the device or prosthesis.
GDA17 2.1.12 / Registers and indexes
Electro Convulsive Therapy, Sedation and Seclusion registers and Rapid tranquillisation journals / Patient/client registration
2.1.12 / No change to retention requirements. Trigger for calculation of retention period changed from last entry to action completed to accommodate electronic/digital format registers.
GDA17 2.1.13 / Registers and indexes
Duplicate registration and index records / Duplicate records can be disposed of under the normal administrative practice provisions of the Act.