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.
equipment 1.18.1 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 Patient/client registration Retention requirements changed
Register of surgically implanted devices 2.1.11 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. GDA17 2.2.1 Lists and schedules In-patient admission, transfer, discharge or death lists Patient/client administration 2.8.1 Administrative arrangements for the management of patients/clients No change to retention requirements. GDA17 2.2.2 Lists and schedules Operation and theatre booking lists & schedules Patient/client administration 2.8.1 Administrative arrangements for the management of patients/clients No change to retention requirements. GDA17 2.2.3 Lists and schedules Clinical lists Patient/client administration 2.8.1 Administrative arrangements for the management of patients/clients Increase in retention period from 1 year after date of last entry to minimum of 2 years after action competed. GDA17 2.2.4 Lists and schedules Quarterly waiting list surveys Patient/client administration 2.8.1 Administrative arrangements for the management of patients/clients Increase in retention period from 1 year after survey to minimum of 2 years after action completed. GDA17 2.2.5 Lists and schedules Waiting lists - clerical audit reports Patient/client administration 2.8.1 Administrative arrangements for the management of patients/clients Retention period reduced from 3 years after audit to minimum of 2 years after action completed. GDA17 2.2.6 Lists and schedules Recommendation for admission forms Patient/client administration 2.8.1 Retention period reduced from 3 years after creation to minimum
where the patient did not attend Administrative arrangements for the management of patients/clients of 2 years after action completed GDA17 2.3.1 Diaries and appointment books recording details of client contact not recorded elsewhere Patient/client administration 2.8.2 Records relating to the clinical administration or management of client/patients documenting contact not recorded elsewhere No change to retention requirements. GDA17 2.3.2 Diaries and appointment books recording basic information or details See General retention and disposal authority: administrative records (STRATEGIC MANAGEMENT - Meetings) No change to retention requirements. GDA17 2.4.1 Censuses and returns Reports or returns re numbers of patients admitted or transferred Patient/client administration 2.8.1 Administrative arrangements for the management of patients/clients Increase in retention period from 1 year after date of creation or completion of audit to minimum of 2 years after action completed. GDA17 2.4.2 Censuses and returns Originals of data collection forms and returns held by the Department of Health See Retention and disposal authority: NSW Department of Health - data collection forms (DA57) GDA17 2.4.3 Censuses and returns Copies of [submitted] data collection records/returns held by public health organisations Patient/client administration 2.8.1 Administrative arrangements for the management of patients/clients Increase in retention period from 1 year after date of submission to minimum of 2 years after action completed. GDA17 2.5.1 Records relating to the management, treatment and care of patients on the ward Patient/client registration 2.1.10 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. No change to retention requirements. GDA17 2.6.1 Systems that consist of and manage patient data re admission, discharge, etc. Entry for electronic patient management systems removed. Records in electronic format should be retained and disposed of as per
birth if date of death unknown. GDA17 3.3.2 Diagnostic graphical recordings where an abnormality is detected Imaging and Recording Services 3.3.1 Recordings of diagnostic procedures. Removal of requirement to retain recordings at least until patient reaches age 25. GDA17 3.3.3 Diagnostic graphical recordings where no abnormality is detected Imaging and Recording Services 3.3.1 Recordings of diagnostic procedures. Increases retention requirements for diagnostic graphical recordings where there is no abnormality detected from retain until administrative use ceases to minimum of 7 years after attendance. GDA17 3.4.1 Registers - diagnostic recordings Imaging and Recording Services 3.4.1 Registers or associated control records No change to retention requirements. Disposal action amended to until administrative or reference use ceases. GDA17 reference Function/Activity/Records Draft reference Comments PATIENT DIAGNOSIS – Pathology and laboratory services DIAGNOSTIC SERVICES – Pathology and laboratory services GDA17 4.1.1 Diagnostic pathology and laboratory service requests Pathology and laboratory services 4.1.1 Diagnostic service copies of requests for and reports or findings of tests or procedures. Disposal action amended to require retention and permit disposal in accordance with current applicable requirements as outlined in legislation or quality standards, etc. GDA17 4.2.1 Anatomical pathology, cytology and autopsy or post-mortem reports/records, registers, diagrams and copies of any representative images prepared Pathology and laboratory services 4.1.1 Diagnostic service copies of requests for and reports or findings of tests or procedures. Disposal action amended to require retention and permit disposal in accordance with current applicable requirements as outlined in legislation or quality standards, etc. GDA17 4.2.2 Histopathology and bone marrow reports/records Pathology and laboratory services 4.1.1 Disposal action amended to require retention and permit disposal in
GDA17 6.2.3 Duplicate records of notifications subsequently received Notifications 6.2.2 Reports of an incidence of a notifiable disease received by Public Health Units. No change to retention requirements. Duplicate notifications received subsequent to the initial notification can be disposed of when no longer required for administrative or reference purposes GDA17 reference Function/Activity/Records Draft reference Comments PATIENT/CLIENT FINANCE AND PROPERTY MANAGEMENT PATIENT/CLIENT REGISTRATION AND MANAGEMENT GDA17 7.1.1 Patient property and wearing apparel books Patient/client administration 2.8.3 Records documenting the management of patient/client property, accounts and finances. Increase in retention period from 6 to minimum of 7 years GDA17 7.1.2 Patient moneys and valuables register Patient/client administration 2.8.3 Records documenting the management of patient/client property, accounts and finances. Increase in retention period from 6 to minimum of 7 years. Trigger changed from date of last entry to action completed. GDA17 7.1.3 Patient moneys and valuables register where copy maintained with patient record Patient/client administration 2.8.4 Records relating to the handling of patient/client's property or finances which are not the primary record. Increase in retention period from 1 to minimum of 2 years. Trigger changed from date of last entry to action completed GDA17 7.1.4 Patient/client authorities to make payment Patient/client administration 2.8.3 Records documenting the management of patient/client property, accounts and finances. Increase in retention period from 6 to minimum of 7 years. Trigger changed from date of last entry to action completed. GDA17 7.2.1 Assigned benefits claim books Patient/client administration Increase in retention period from