2.0.0 Patient/client registration and administration
The function of managing the identification, registration, admission, transfer and discharge of patients/clients.
See Pre-1930 records for records created prior to 1930.
2.1.0 Patient/client registers and indexes
The management of registers and summary information relating to patient/client admission, identification, transfer, discharge and treatment.
Note: registers etc. of private hospitals, services, nursing homes, centres etc. are not State records and should be retained and disposed of in accordance with any requirements of the Act or regulations under which the establishment is licensed.
See Patient/client treatment and care - Complaints and incident management for registers of patient injuries, complaints or incidents
See Pharmaceutical supply and administration for drug registers maintained on wards.
| No. | Description of records | Disposal action |
|---|
| 2.1.1 | Patient/client registration information supporting unique identification of patients/clients. This may include patient/client identification or record number and associated patient/client details (name, date of birth, sex, address, etc.) that enables unique identification to support ongoing provision of treatment, care and services. May also include associated patient administration details such as health insurance details, next of kin or guardian, concession eligibility, etc. | Retain until administrative or reference use ceases (i.e. until information would no longer be required to support unique identification and ongoing provision of care to registered patient/client or for potential legal action, research, accountability or other reference purposes associated with the provision of treatment/care to the patient/client), then destroy |
| 2.1.2 | Hospital and emergency department patient registration or administration information providing summary details of births, deaths(including mortuary admissions), patients admitted, presenting, treated and discharged, length of stay and the nature of treatment and care provided (e.g. admission and discharge diagnosis, surgical procedures and operations performed). | Required as State archives |
| 2.1.3 | Registers or indexes documenting physicians and medical practitioners with admitting rights and details of patients attended. | Retain until patient attains or would have attained the age of 25 years or minimum of 15 years after date of last entry, whichever is longer, then destroy |
2.1.4- 2.1.8 | See entry 2.1.2. | |
| 2.1.9 | Registers or summary presenting/treatment data for community health patient/clients and Ambulance and emergency transport patient/clients. Note: see entry 2.1.1above for patient/client identification information. | Retain until patient attains or would have attained the age of 25 years or minimum of 15 years after action completed, whichever is longer, then destroy |
| 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. | Retain minimum of 7 years after last entry or action completed, then destroy |
| 2.1.11 | Register of surgically implanted devices or prostheses. | Retain minimum of 75 years after implantation of the device or prosthesis, then destroy |
| 2.1.12 | Registers or summary records documenting the administration of electro-convulsive therapy or sedation or seclusion of mental health patients. | Retain minimum of 15 years after action completed, then destroy |
No. 2.1.1 Description of records Patient/client registration information supporting unique identification of patients/clients. This may include patient/client identification or record number and associated patient/client details (name, date of birth, sex, address, etc.) that enables unique identification to support ongoing provision of treatment, care and services. May also include associated patient administration details such as health insurance details, next of kin or guardian, concession eligibility, etc. Disposal action Retain until administrative or reference use ceases (i.e. until information would no longer be required to support unique identification and ongoing provision of care to registered patient/client or for potential legal action, research, accountability or other reference purposes associated with the provision of treatment/care to the patient/client), then destroy |
No. 2.1.2 Description of records Hospital and emergency department patient registration or administration information providing summary details of births, deaths(including mortuary admissions), patients admitted, presenting, treated and discharged, length of stay and the nature of treatment and care provided (e.g. admission and discharge diagnosis, surgical procedures and operations performed). Disposal action Required as State archives |
No. 2.1.3 Description of records Registers or indexes documenting physicians and medical practitioners with admitting rights and details of patients attended. Disposal action Retain until patient attains or would have attained the age of 25 years or minimum of 15 years after date of last entry, whichever is longer, then destroy |
No. Description of records See entry 2.1.2. Disposal action |
No. 2.1.9 Description of records Registers or summary presenting/treatment data for community health patient/clients and Ambulance and emergency transport patient/clients. Note: see entry 2.1.1above for patient/client identification information. Disposal action Retain until patient attains or would have attained the age of 25 years or minimum of 15 years after action completed, whichever is longer, then destroy |
No. 2.1.10 Description of records 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. Disposal action Retain minimum of 7 years after last entry or action completed, then destroy |
No. 2.1.11 Description of records Register of surgically implanted devices or prostheses. Disposal action Retain minimum of 75 years after implantation of the device or prosthesis, then destroy |
No. 2.1.12 Description of records Registers or summary records documenting the administration of electro-convulsive therapy or sedation or seclusion of mental health patients. Disposal action Retain minimum of 15 years after action completed, then destroy |
2.2.0 Patient/client administration
Administration of arrangements for the provision of treatment, care or services to patients/clients. Includes the management of patient property, accounts and finances and provision of disability equipment.
See Patient/client registration and management - Patient/client registration for patient registers.
See General Retention and Disposal Authority Administrative records Strategic management - Meetings for diaries and appointment books of staff that do not record patient/client contact.
| No. | Description of records | Disposal action |
|---|
| 2.2.1 | Records relating to administrative arrangements for the management of patients/clients. Includes: - lists and booking schedules
- routine census or data collection reports or returns
- referrals, requests for services and recommendations for admission where patient/client did not attend.
Note: applies whether the patients have a medical record or not Note: for time periods where admission, discharge, death, operation or theatre registers do not exist, the equivalent admission, discharge, etc., lists may warrant retention as State archives. Contact State Records Authority NSW to discuss. | Retain minimum of 2 years after action completed, then destroy |
2.2.2- 2.2.6 | See entry 2.2.1. | |
| 2.3.1 | Records relating to the clinical administration or management of client/patients documenting contact not recorded elsewhere e.g. diaries and appointment books, copies of service requests or referrals, requests for or copies of issued medical certificates, etc. | Retain minimum of 7 years after action completed, then destroy |
| 2.3.2 | Removed see GA28 Strategic management - Meetings (19.3.3). | |
| 2.4.1 | See entry 2.2.1. | |
| 2.4.2 | Entry removed as covered by Normal Administrative Practice guidelines. | |
| 2.4.3 | See entry 2.2.1. | |
| 2.5.1 | See entry 2.1.10. | |
| 2.6.1 | See entry 2.1.1. | |
| 2.7.1 | See GA28 Strategic management - Reporting or Government relations - Reporting. | |
No. 2.2.1 Description of records Records relating to administrative arrangements for the management of patients/clients. Includes: - lists and booking schedules
- routine census or data collection reports or returns
- referrals, requests for services and recommendations for admission where patient/client did not attend.
Note: applies whether the patients have a medical record or not Note: for time periods where admission, discharge, death, operation or theatre registers do not exist, the equivalent admission, discharge, etc., lists may warrant retention as State archives. Contact State Records Authority NSW to discuss. Disposal action Retain minimum of 2 years after action completed, then destroy |
No. Description of records See entry 2.2.1. Disposal action |
No. Description of records Records relating to the clinical administration or management of client/patients documenting contact not recorded elsewhere e.g. diaries and appointment books, copies of service requests or referrals, requests for or copies of issued medical certificates, etc. Disposal action Retain minimum of 7 years after action completed, then destroy |
No. 2.3.2 Description of records Disposal action |
No. 2.4.1 Description of records See entry 2.2.1. Disposal action |
No. 2.4.2 Description of records Disposal action |
No. 2.4.3 Description of records See entry 2.2.1. Disposal action |
No. 2.5.1 Description of records See entry 2.1.10. Disposal action |
No. 2.6.1 Description of records See entry 2.1.1. Disposal action |
No. 2.7.1 Description of records Disposal action |
