Public health services client patient records (GDA17)

Pathology and laboratory services

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4.0.0 Pathology and laboratory services

Medical pathology and laboratory diagnostic services. This includes anatomical pathology, cytology, haematology, clinical chemistry/clinical pathology, blood banks, immunology, microbiology and genetics.

No.Description of recordsDisposal action
4.1.1Diagnostic service copies of requests or referrals for and reports or findings of diagnostic procedures, tests or services. Includes associated declarations, consents, etc.Retain in accordance with the relevant legislative requirements and/or national standards and guidelines (for example standards and guidelines issued by the National Pathology Accreditation Advisory Council or its successor agency/ies)

4.2.1-

4.2.6

See entry 4.1.1. 
4.2.7See relevant patient record for records documenting diagnostic findings. 
4.3.1Class removed. Bodily specimens, samples or materials are not considered to be records within the meaning of the State Records Act and are not covered by this authority. They should be managed, retained and disposed of in accordance with relevant legislation or standards and guidelines issued by an appropriate body e.g. National Pathology Accreditation Advisory Council (NPAAC). 
4.3.2

Records relating to the tracking or monitoring of testing completion and the management or control of received or collected bodily parts or specimens.

Includes registers and other associated control records maintained for the purposes of identifying or locating specimens.

Note: Retention periods should be in accordance with the minimum retention periods required for the types of specimens recorded in the register, and where these records contain the details of the disposal of individual specimens, the records should be retained for as long as they might conceivably be required for the purposes of accounting for the disposal of the specimen.

Retain until administrative or reference use ceases, then destroy

4.3.3-

4.3.4

See entry 4.3.2. 
4.3.5See entry 4.1.1. 
4.4.1See entry 4.1.1. 
4.4.2Records of blood, blood product and semen donation and supply. Includes donor records and consents and records documenting the supply of products.Retain in accordance with the relevant legislative requirements and/or national standards and guidelines (for example standards and guidelines issued by the National Pathology Accreditation Advisory Council or its successor agency/ies)

4.4.3,

4.4.4,

4.5.1

See entry 4.4.2. 
4.6.1

Records relating to:

  • quality control and assurance (certification, implementation and audit of processes and services)
  • the maintenance and servicing of equipment used for diagnostic or testing purposes
  • methodologies and standard procedures for the conduct of diagnostic tests and procedures.
Retain in accordance with the relevant legislative requirements and/or national standards and guidelines (for example standards and guidelines issued by the National Pathology Accreditation Advisory Council or its successor agency/ies)

4.7.1,

4.8.1

See entry 4.6.1. 
No.
4.1.1
Description of records
Diagnostic service copies of requests or referrals for and reports or findings of diagnostic procedures, tests or services. Includes associated declarations, consents, etc.
Disposal action
Retain in accordance with the relevant legislative requirements and/or national standards and guidelines (for example standards and guidelines issued by the National Pathology Accreditation Advisory Council or its successor agency/ies)
No.

4.2.1-

4.2.6

Description of records
See entry 4.1.1.
Disposal action
 
No.
4.2.7
Description of records
See relevant patient record for records documenting diagnostic findings.
Disposal action
 
No.
4.3.1
Description of records
Class removed. Bodily specimens, samples or materials are not considered to be records within the meaning of the State Records Act and are not covered by this authority. They should be managed, retained and disposed of in accordance with relevant legislation or standards and guidelines issued by an appropriate body e.g. National Pathology Accreditation Advisory Council (NPAAC).
Disposal action
 
No.
4.3.2
Description of records

Records relating to the tracking or monitoring of testing completion and the management or control of received or collected bodily parts or specimens.

Includes registers and other associated control records maintained for the purposes of identifying or locating specimens.

Note: Retention periods should be in accordance with the minimum retention periods required for the types of specimens recorded in the register, and where these records contain the details of the disposal of individual specimens, the records should be retained for as long as they might conceivably be required for the purposes of accounting for the disposal of the specimen.

Disposal action
Retain until administrative or reference use ceases, then destroy
No.

4.3.3-

4.3.4

Description of records
See entry 4.3.2.
Disposal action
 
No.
4.3.5
Description of records
See entry 4.1.1.
Disposal action
 
No.
4.4.1
Description of records
See entry 4.1.1.
Disposal action
 
No.
4.4.2
Description of records
Records of blood, blood product and semen donation and supply. Includes donor records and consents and records documenting the supply of products.
Disposal action
Retain in accordance with the relevant legislative requirements and/or national standards and guidelines (for example standards and guidelines issued by the National Pathology Accreditation Advisory Council or its successor agency/ies)
No.

4.4.3,

4.4.4,

4.5.1

Description of records
See entry 4.4.2.
Disposal action
 
No.
4.6.1
Description of records

Records relating to:

  • quality control and assurance (certification, implementation and audit of processes and services)
  • the maintenance and servicing of equipment used for diagnostic or testing purposes
  • methodologies and standard procedures for the conduct of diagnostic tests and procedures.
Disposal action
Retain in accordance with the relevant legislative requirements and/or national standards and guidelines (for example standards and guidelines issued by the National Pathology Accreditation Advisory Council or its successor agency/ies)
No.

4.7.1,

4.8.1

Description of records
See entry 4.6.1.
Disposal action
 

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