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Public health services administrative records (GDA21)
Clinical services
2.0.0 Clinical services
The provision of medical, dental, surgical, mental health services etc usually within a hospital or health services facility. This includes management of the expectations, requirements and quality of clinical practice and the provision of allied health, rehabilitation, pastoral, interpreter or other services directly relating to the provision of patient care.
See General Retention and Disposal Authority – Public Health Services: Patient/Client records for records relating to the treatment and care of individual patients.
See Corporate management – Committees for records of Appointments, Creditation, Practitioner committees etc.
See Corporate management – Planning for records relating to strategic planning processes or business and operational plans for individual programs, units or facilities.
See Corporate support services for records relating to services such as Accommodation, Linen Supply, Food Services, Cleaning etc.
See Equipment (Medical) for records relating to the acquisition and maintenance of medical equipment, including biomedical engineering services.
See Personnel for records relating to the terms and conditions of employment for visiting practitioners.
See Service development for records relating to the analysis of service needs and planning for area or service wide delivery of services.
2.1.0 Agreements
Processes associated with the establishment, maintenance, review and negotiation of agreements.
No | Classes of records | Disposal Action |
|---|---|---|
2.1.1 | Records relating to formal agreements, contracts or arrangements for the provision or delivery of services. This includes records relating to the negotiation, implementation and review of the agreement. | Retain minimum of 7 years after expiry of the agreement or last action, whichever is the longer, then destroy |
2.1.2 | Records relating to collaborative partnerships, arrangements or networks with other service providers | Retain minimum of 5 years after last action, then destroy |
No 2.1.1 Classes of records Records relating to formal agreements, contracts or arrangements for the provision or delivery of services. This includes records relating to the negotiation, implementation and review of the agreement. Disposal Action Retain minimum of 7 years after expiry of the agreement or last action, whichever is the longer, then destroy |
No 2.1.2 Classes of records Records relating to collaborative partnerships, arrangements or networks with other service providers Disposal Action Retain minimum of 5 years after last action, then destroy |
2.20 Audits
Activities associated with officially checking operational records, processes or systems for the purposes of ensuring compliance with standards, policies, procedures etc
See General Retention and Disposal Authority – Public Health Services: Patient/Client records for records relating to audits carried out for the purposes of evidence based quality management assessments of treatments or patient management practices and for records relating to audits carried out in relation to incidents or investigations
See Reviewing for records of ad hoc audits carried out as part of program or service review processes
2.3.0 Compliance
Activities associated with complying with legal or regulatory requirements or international or national healthcare and quality management standards.
| No | Classes of records | Disposal Action |
|---|---|---|
2.3.1 | Records relating to the accreditation or certification of services or facilities by external National, State, industry and/or professional bodies. | Retain minimum of 5 years after accreditation renewed or lapses, then destroy |
No 2.3.1 Classes of records Records relating to the accreditation or certification of services or facilities by external National, State, industry and/or professional bodies. Disposal Action Retain minimum of 5 years after accreditation renewed or lapses, then destroy |
2.4.0 Evaluation
Activities associated with measuring the effectiveness, efficiency and accessibility of services, programs etc to determine their suitability or assess their performance. This includes ongoing monitoring activities.
| No | Classes of records | Disposal Action |
|---|---|---|
2.4.1 | Records relating to the evaluation of new services or programs for the purposes of assessing their suitability to continue or for broader uptake and implementation. | Required as State archives |
2.4.2 | Records relating to the evaluation of existing programs, practices, methods, service systems, technology etc employed in the provision of services. This includes records relating to the conduct of surveys (eg patient satisfaction surveys), benchmarking activities and comparative or analysis reports generated from the monitoring of activities, performance and outcomes of care. | Retain minimum of 10 years after last action, then destroy |
No 2.4.1 Classes of records Records relating to the evaluation of new services or programs for the purposes of assessing their suitability to continue or for broader uptake and implementation. Disposal Action Required as State archives |
No 2.4.2 Classes of records Records relating to the evaluation of existing programs, practices, methods, service systems, technology etc employed in the provision of services. This includes records relating to the conduct of surveys (eg patient satisfaction surveys), benchmarking activities and comparative or analysis reports generated from the monitoring of activities, performance and outcomes of care. Disposal Action Retain minimum of 10 years after last action, then destroy |
2.5.0 Incident management
Activities associated with managing and responding to incidents involving patients, this includes sentinel and adverse events1.
SeeGeneral Retention and Disposal Authority – Public Health Services: Patient/Client records for records relating to the management and handling of complaints, incidents, investigations (including root cause analysis (RAC) investigations) and/or litigation involving the health facility and its patients/clients
See Government relations for records relating to the reporting of complaints or incidents to external organisations eg NSW Department of Health, Health Care Complaints Commission, Professional Registration bodies
See General Retention and Disposal Authority – Administrative records Government relations – Inquiries for records relating to formal Inquiries or investigations by external bodies
See alsoGeneral Retention and Disposal Authority – Personnel records for records relating to the handling of complaints or incidents concerning members of staff or individual clinicians
2.6.0 Liaison
Activities associated with maintaining regular general contact between the organisation and other related professionals, professional associations, private sector organisations, non-government or community groups etc. Includes provision of advice or information of a routine nature, information sessions and general discussions and collaboration on projects that are not joint ventures.
See Service development for records relating to consultation with other service providers, community groups, professional associations, industry groups etc for planning and service development purposes.
See General Retention and Disposal Authority – Public Health Services: Patient/Client records for records of correspondence or liaison with another service provider concerning an individual patient.
| No | Classes of records | Disposal Action |
|---|---|---|
2.6.1 | Records relating to routine liaison with other organisations or service providers concerning service arrangements or for information sharing purposes | Retain minimum of 2 years after last action, then destroy |
No 2.6.1 Classes of records Records relating to routine liaison with other organisations or service providers concerning service arrangements or for information sharing purposes Disposal Action Retain minimum of 2 years after last action, then destroy |
2.7.0 Meetings
The activities associated with meetings held to formulate, discuss, update or resolve issues or matters pertaining to the management of the service or unit
See Corporate management – Committees for records of committee meetings.
| No | Classes of records | Disposal Action |
|---|---|---|
2.7.1 | Records relating to the conduct of unit level meetings concerning clinical performance issues eg Morbidity & Mortality meetings, Peer Review meetings etc. This includes records of meeting agendas, minutes, background papers and reports. | Retain minimum of 7 years after last action, then destroy |
2.7.2 | Records relating to the conduct of meetings for routine operational purposes eg team or section meetings | Retain minimum of 5 years after last action, then destroy |
No 2.7.1 Classes of records Records relating to the conduct of unit level meetings concerning clinical performance issues eg Morbidity & Mortality meetings, Peer Review meetings etc. This includes records of meeting agendas, minutes, background papers and reports. Disposal Action Retain minimum of 7 years after last action, then destroy |
No 2.7.2 Classes of records Records relating to the conduct of meetings for routine operational purposes eg team or section meetings Disposal Action Retain minimum of 5 years after last action, then destroy |
2.8.0 Policy & Procedures
Activities associated with the development of local operational policies, procedures, protocols etc relating to clinical practices.
No | Classes of records | Disposal Action |
|---|---|---|
2.8.1 | Collections of clinical policies, procedures guidelines etc documenting the practices of a particular facility or service and of value for social or medical research purposes | Required as State archives |
2.8.2(a) | Records relating to locally developed policies, procedures, protocols or guidelines concerning clinical practices. Includes records of proposals, background research, consultation and master copies of adopted policies, procedures etc and associated circulars. | Retain minimum of 25 years after superseded, then destroy |
2.8.2(b) | Records relating to routine implementation of or minor changes to practices (but where no changes to policy are made) | Retain minimum of 5 years after action completed, then destroy |
No 2.8.1 Classes of records Collections of clinical policies, procedures guidelines etc documenting the practices of a particular facility or service and of value for social or medical research purposes Disposal Action Required as State archives |
No 2.8.2(a) Classes of records Records relating to locally developed policies, procedures, protocols or guidelines concerning clinical practices. Includes records of proposals, background research, consultation and master copies of adopted policies, procedures etc and associated circulars. Disposal Action Retain minimum of 25 years after superseded, then destroy |
No 2.8.2(b) Classes of records Records relating to routine implementation of or minor changes to practices (but where no changes to policy are made) Disposal Action Retain minimum of 5 years after action completed, then destroy |
2.9.0 Programs
Activities associated with the administration of particular health care programs.
| No | Classes of records | Disposal Action |
|---|---|---|
2.9.1 | Records relating to the administration of drugs or other specialised programs eg the methadone or highly specialised drugs program. This includes records of submissions, applications, approvals, authorisations and arrangements concerning the conduct of the program. | Retain minimum of 10 years after action completed, then destroy |
No 2.9.1 Classes of records Records relating to the administration of drugs or other specialised programs eg the methadone or highly specialised drugs program. This includes records of submissions, applications, approvals, authorisations and arrangements concerning the conduct of the program. Disposal Action Retain minimum of 10 years after action completed, then destroy |
2.10.0 Reporting
The provision of a formal response to a situation or request for information or as a requirement concerning aspects of the organisation’s responsibilities, performance or activities.
See also Corporate management – Reporting.
| No | Classes of records | Disposal Action |
|---|---|---|
2.10.1 | Returns and survey data provided by or to services for collation for reporting and monitoring purposes | Retain until the records are no longer required for administrative, data verification or reference purposes, then destroy |
No 2.10.1 Classes of records Returns and survey data provided by or to services for collation for reporting and monitoring purposes Disposal Action Retain until the records are no longer required for administrative, data verification or reference purposes, then destroy |
2.11.0 Reviewing
Activities associated with the examination of processes, procedures, systems or outcomes for the purposes of assessing the performance, quality or suitability of services, programs etc.
See General Retention and Disposal Authority – Personnel records for records relating to complaints concerning or reviews of an individual clinician’s performance.
No | Classes of records | Disposal Action |
|---|---|---|
2.11.1 | Records relating to the conduct of reviews establishing the need for major reform or restructure of programs or services | Required as State archives |
2.11.2 | Records relating to the conduct and outcomes of reviews or ad hoc audits of specific clinical practices, procedures or services eg chart or medical record reviews | Retain minimum of 6 years after last action, then destroy |
No 2.11.1 Classes of records Records relating to the conduct of reviews establishing the need for major reform or restructure of programs or services Disposal Action Required as State archives |
No 2.11.2 Classes of records Records relating to the conduct and outcomes of reviews or ad hoc audits of specific clinical practices, procedures or services eg chart or medical record reviews Disposal Action Retain minimum of 6 years after last action, then destroy |
2.12.0 Service provision
Activities associated with the provision of auxiliary services to patients/clients
See General Retention and Disposal Authority – Public Health Services: Patient/Client records for records relating to the provision of treatment and care to individual patients of allied health, rehabilitation, social work services etc.
See the General retention and disposal authority: administrative records Personnel – Misconduct for records relating to the management of complaints or allegations involving staff.
No | Classes of records | Disposal Action |
|---|---|---|
2.12.1 | Records relating to the provision of pastoral care. This includes records of requests and referrals for patient visits (including log books etc), arrangements for memorial or funeral services, provision of sacraments etc. | Retain minimum of 3 years after last action, then destroy |
2.12.2 | Records relating to requests and arrangements for the provision of interpreter services for individual patients/clients | Retain minimum of 3 years after last action, then destroy |
No 2.12.1 Classes of records Records relating to the provision of pastoral care. This includes records of requests and referrals for patient visits (including log books etc), arrangements for memorial or funeral services, provision of sacraments etc. Disposal Action Retain minimum of 3 years after last action, then destroy |
No 2.12.2 Classes of records Records relating to requests and arrangements for the provision of interpreter services for individual patients/clients Disposal Action Retain minimum of 3 years after last action, then destroy |
2.13.0 Staff qualifications
The processes associated with determining appropriate requirements or qualifications for clinical practice to meet the needs of the organisation or area.
See Corporate management – Committees for records relating to the determination of clinical privileges or credentials of individual practitioners.
| No | Classes of records | Disposal Action |
|---|---|---|
2.13.1 | Records relating to consultation with external bodies such as educational institutes or professional associations regarding the determination of appropriate qualifications, experience and continuing education/professional development requirements for clinical positions | Retain minimum of 10 years after last action, then destroy |
2.13.2 | Records relating to determining the qualifications and experience of practitioners required to meet the particular health needs of the area | Retain minimum of 10 years after last action, then destroy |
No 2.13.1 Classes of records Records relating to consultation with external bodies such as educational institutes or professional associations regarding the determination of appropriate qualifications, experience and continuing education/professional development requirements for clinical positions Disposal Action Retain minimum of 10 years after last action, then destroy |
No 2.13.2 Classes of records Records relating to determining the qualifications and experience of practitioners required to meet the particular health needs of the area Disposal Action Retain minimum of 10 years after last action, then destroy |
2.14.0 Standards
The process of implementing standards, benchmarks or indicators to measure and enhance the quality and performance of the organisation.
No | Classes of records | Disposal Action |
|---|---|---|
2.14.1 | Records relating to the development of standards, benchmarks or indicators as measures of clinical management, performance or outcomes of care | Retain minimum of 10 years after superseded, then destroy |
2.14.2 | Copies of care standards, performance indicators etc developed by other organisations that provide guidance on how performance is to be measured | Retain minimum of 5 years after superseded, then destroy |
No 2.14.1 Classes of records Records relating to the development of standards, benchmarks or indicators as measures of clinical management, performance or outcomes of care Disposal Action Retain minimum of 10 years after superseded, then destroy |
No 2.14.2 Classes of records Copies of care standards, performance indicators etc developed by other organisations that provide guidance on how performance is to be measured Disposal Action Retain minimum of 5 years after superseded, then destroy |