3.0.0 Diagnostic imaging and recording services
The conduct of procedures and tests for the purpose of patient/client diagnosis. This includes diagnostic imaging, pathology and laboratory services such as diagnostic radiology, tomography, nuclear medicine, ultrasound, magnetic resonance imaging and related diagnostic digital imaging procedures.
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.
| No. | Description of records | Disposal action |
|---|
| 3.1.1 | 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 |
| 3.2.1 | Patient record copy - see relevant patient record. | |
| 3.2.2 | See entry 3.1.1. | |
| 3.3.1 | Recordings of diagnostic and screening 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
- 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. | 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 destroy TB (tuberculosis) chest X-Ray: Retain for life of patient or 85 years from date of birth if date of death unknown, then destroy |
3.3.2 - 3.3.3 | See entry 3.3.1. | |
| 3.4.1 | 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 |
No. 3.1.1 Description of records Diagnostic service copies of requests for and reports or findings of diagnostic procedures, tests or services. Disposal action Retain minimum of 3 years after provision of service or date of report, then destroy |
No. 3.2.1 Description of records Patient record copy - see relevant patient record. Disposal action |
No. 3.2.2 Description of records See entry 3.1.1. Disposal action |
No. 3.3.1 Description of records Recordings of diagnostic and screening 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
- 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. Disposal action 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 destroy TB (tuberculosis) chest X-Ray: Retain for life of patient or 85 years from date of birth if date of death unknown, then destroy |
No. Description of records See entry 3.3.1. Disposal action |
No. 3.4.1 Description of records 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. Disposal action Retain until administrative or reference use ceases, then destroy |
