1.0.0 Patient/client treatment and care
The provision of health assessment, diagnosis, management, treatment and care services and/or advice to individual patients/clients.
Note: records 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 Pre-1930 patient/client records for records created prior to 1930.
See Patient/client registration and administration - Patient/client administration for records documenting booking of non-emergency transport services.
See General Retention and Disposal Authority Administrative records Personnel - Misconduct for records relating to allegations of misconduct against staff, volunteers, work placement students, including allegations of assault against minors.
See General Retention and Disposal Authority Administrative records Personnel - Reporting for records relating to the statutory reporting of incidents or referral of other matters to external bodies such as the Police, Independent Commission Against Corruption, the Ombudsman or child protection agencies e.g. Community Services.
See General Retention and Disposal Authority Administrative records Strategic management - Compliance for records relating to the management of allegations of assault against minors from visitors, other patients etc.
1.1.0 Hospital and emergency care
The provision of treatment, care and services to hospital inpatients, outpatients and accident and emergency patients. Includes the provision of treatment, care and services by ambulance and other transport services.
| No. | Description of records | Disposal action |
|---|
| 1.1.1 | Records documenting the treatment and care of admitted patients of Group A hospitals, e.g. principal referral hospitals providing specialist, acute care, research and teaching services. Note: if the patient record contains the only record of a surgically implanted device then it needs to be retained as per entry 2.1.11. | Retain minimum of 15 years after last attendance or official contact or access by or on behalf of the patient1 or until patient attains or would have attained the age of 25 years, whichever is longer, then destroy |
| 1.1.2 | Records documenting the treatment and care of admitted patients of Group B to F hospitals and services, e.g. nursing homes, rehabilitation facilities, hospices and hospitals that are not principal referral, paediatric specialist or acute hospitals. | Retain minimum of 10 years after last attendance or official contact or access by or on behalf of the patient2 or until patient attains or would have attained the age of 25 years, whichever is longer, then destroy |
| 1.1.3 | Records documenting the treatment and care of patients attending or presenting at emergency and/or out-patient clinics that are not admitted as patients, including patients who are dead on arrival. | Retain minimum of 7 years after last attendance or official contact or access by or on behalf of the patient or until patient attains or would have attained the age of 25 years, whichever is longer, then destroy |
| 1.1.4 | Records documenting the treatment and care of ambulance, emergency and non-emergency transport service patients/clients. Note: this entry covers records created by ambulance and patient transport services. | Retain minimum of 7 years after provision of service or after last official contact or access by or on behalf of the patient or until patient attains or would have attained the age of 25 years, whichever is longer, then destroy |
No. 1.1.1 Description of records Records documenting the treatment and care of admitted patients of Group A hospitals, e.g. principal referral hospitals providing specialist, acute care, research and teaching services. Note: if the patient record contains the only record of a surgically implanted device then it needs to be retained as per entry 2.1.11. Disposal action Retain minimum of 15 years after last attendance or official contact or access by or on behalf of the patient1 or until patient attains or would have attained the age of 25 years, whichever is longer, then destroy |
No. 1.1.2 Description of records Records documenting the treatment and care of admitted patients of Group B to F hospitals and services, e.g. nursing homes, rehabilitation facilities, hospices and hospitals that are not principal referral, paediatric specialist or acute hospitals. Disposal action Retain minimum of 10 years after last attendance or official contact or access by or on behalf of the patient2 or until patient attains or would have attained the age of 25 years, whichever is longer, then destroy |
No. 1.1.3 Description of records Records documenting the treatment and care of patients attending or presenting at emergency and/or out-patient clinics that are not admitted as patients, including patients who are dead on arrival. Disposal action Retain minimum of 7 years after last attendance or official contact or access by or on behalf of the patient or until patient attains or would have attained the age of 25 years, whichever is longer, then destroy |
No. 1.1.4 Description of records Records documenting the treatment and care of ambulance, emergency and non-emergency transport service patients/clients. Note: this entry covers records created by ambulance and patient transport services. Disposal action Retain minimum of 7 years after provision of service or after last official contact or access by or on behalf of the patient or until patient attains or would have attained the age of 25 years, whichever is longer, then destroy |
1'access by or on behalf of the patient' refers to any use made of the record or access to the records for any purpose directly concerning the patient, such as attendance by the patient, provision of a report to another health care worker or agency, access under subpoena, inspection by the patient or their legal representative. Access for research, quality assurance, audit or educational purposes or by next of kin checking medical history does not constitute access by or on behalf of the patient
2 'access by or on behalf of the patient' refers to any use made of the record or access to the records for any purpose directly concerning the patient, such as provision of a report to another health care worker or agency, access under subpoena, inspection by the patient or their legal representative. Access for research, quality assurance, audit or educational purposes or by next of kin checking medical history does not constitute access by or on behalf of the patient.
The provision of treatment and care to patients/clients through community based health care facilities, centres or services, including services provided at patient's place of residence. This includes unregistered clients, clients who are screened without follow up, potential clients or clients who are referred elsewhere.
| No. | Description of records | Disposal action |
|---|
| 1.2.1 | Records documenting the provision of treatment, care, assessment, screening and other services to community clients. Includes: - immunisations
- audiology and eyesight screenings
- breast screening and other imaging services
- child, family health and school screening.
| Retain minimum of 7 years after last attendance or official contact or access by or on behalf of the client or until patient attains or would have attained the age of 25 years, whichever is longer, then destroy TB (tuberculosis) service/Chest Clinic patients: Retain minimum of 15 years after last attendance or official contact by or on behalf of the patient or until patient attains or would have attained the age of 25 years, whichever is longer, then destroy |
1.2.2- 1.2.7 | See entry 1.2.1. | |
| 1.2.8 | Criminal histories of clients referred by Courts under rehabilitation or treatment programs e.g. Magistrates Early Referral into Treatment (MERIT)Program, Adult Drug Court etc. | Retain until conclusion of client's active involvement in program, then destroy |
No. 1.2.1 Description of records Records documenting the provision of treatment, care, assessment, screening and other services to community clients. Includes: - immunisations
- audiology and eyesight screenings
- breast screening and other imaging services
- child, family health and school screening.
Disposal action Retain minimum of 7 years after last attendance or official contact or access by or on behalf of the client or until patient attains or would have attained the age of 25 years, whichever is longer, then destroy TB (tuberculosis) service/Chest Clinic patients: Retain minimum of 15 years after last attendance or official contact by or on behalf of the patient or until patient attains or would have attained the age of 25 years, whichever is longer, then destroy |
No. Description of records See entry 1.2.1. Disposal action |
No. 1.2.8 Description of records Criminal histories of clients referred by Courts under rehabilitation or treatment programs e.g. Magistrates Early Referral into Treatment (MERIT)Program, Adult Drug Court etc. Disposal action Retain until conclusion of client's active involvement in program, then destroy |
1.3.0 Oral (dental) health care
The provision of treatment, care and services to clients of oral (dental) health care services.
| No. | Description of records | Disposal action |
|---|
| 1.3.1 | Records documenting the examination, assessment and treatment of dental patients/clients. Includes dental charts, consent forms, x-rays etc. | Retain minimum of 7 years after last attendance or official contact or access by or on behalf of the client or until patient attains or would have attained the age of 25 years, whichever is longer, then destroy |
| 1.3.2 | Records documenting consent for non-interventional school screening activities and school screening results that do not indicate need for further treatment, care or interventional action (i.e. no abnormality detected). | Retain minimum of 7 years after action completed, then destroy |
No. 1.3.1 Description of records Records documenting the examination, assessment and treatment of dental patients/clients. Includes dental charts, consent forms, x-rays etc. Disposal action Retain minimum of 7 years after last attendance or official contact or access by or on behalf of the client or until patient attains or would have attained the age of 25 years, whichever is longer, then destroy |
No. 1.3.2 Description of records Records documenting consent for non-interventional school screening activities and school screening results that do not indicate need for further treatment, care or interventional action (i.e. no abnormality detected). Disposal action Retain minimum of 7 years after action completed, then destroy |
1.4.0 Obstetric/maternal health care
The management of births, including adoption processes. Includes any pregnancy that results in the birth of a baby where birth registration is required under the Births, Deaths and Marriages Act, including live and still births.
See Patient/client treatment and care - Hospital and emergency care and Community based health care for records relating to the care and treatment of mother and child.
| No. | Description of records | Disposal action |
|---|
| 1.4.1 | Records documenting birth episodes. Includes: - the mother's antenatal records, including any antenatal screening results
- records of the labour, including CTG traces
- medical records relating to the neonatal period and following.
Note: Services need to assess patterns of use and frequency of access requests prior to proceeding to destruction of collections of obstetric records. Services may also want to consider if the collection is of exemplary or other significance warranting retention as State archives under entry 1.12.1. | Retain a minimum of 50 years after date of birthing episode, or 15years after action completed (for Group A Hospitals) or 10 years after action completed (for Group B-F Hospitals), whichever is longer, then destroy |
| 1.4.2 | Records documenting arrangements for adoptions that proceed. Includes associated social work, counselling or support records. | Retain in agency |
No. 1.4.1 Description of records Records documenting birth episodes. Includes: - the mother's antenatal records, including any antenatal screening results
- records of the labour, including CTG traces
- medical records relating to the neonatal period and following.
Note: Services need to assess patterns of use and frequency of access requests prior to proceeding to destruction of collections of obstetric records. Services may also want to consider if the collection is of exemplary or other significance warranting retention as State archives under entry 1.12.1. Disposal action Retain a minimum of 50 years after date of birthing episode, or 15years after action completed (for Group A Hospitals) or 10 years after action completed (for Group B-F Hospitals), whichever is longer, then destroy |
No. 1.4.2 Description of records Records documenting arrangements for adoptions that proceed. Includes associated social work, counselling or support records. Disposal action Retain in agency |
1.5.0 Psychiatric and mental health care
The provision of treatment, care and services to patients under mental health legislation e.g. the Mental Health Act.
See Patient/client registration and administration - Patient/client registers for registers or summary records documenting the administration of electro- convulsive therapy or sedation or seclusion of mental health patients.
See Patient/client treatment and care - Hospital and emergency care or Community based health care for records relating to the treatment and care of patients not covered by the Mental Health Act who have mental health conditions.
Note: 'access by or on behalf of the patient' refers to any use made of the record or access to the records for any purpose directly concerning the patient, such as attendance by the patient, provision of a report to another health care worker or agency, access under subpoena, inspection by the patient or their legal representative. Access for research, quality assurance, audit or educational purposes or by next of kin checking medical history does not constitute access by or on behalf of the patient.| No. | Description of records | Disposal action |
|---|
| 1.5.1 | Records of patients/clients of former Crown operated/5th Schedule psychiatric hospitals where the records were wholly or partly created prior to 1960. | Required as State archives |
| 1.5.2 | Records documenting the treatment and care of patients/clients under mental health legislation e.g. the Mental Health Act. | Retain minimum of 45 years after last attendance or official contact or access by or on behalf of the patient, then destroy |
Note: 'access by or on behalf of the patient' refers to any use made of the record or access to the records for any purpose directly concerning the patient, such as attendance by the patient, provision of a report to another health care worker or agency, access under subpoena, inspection by the patient or their legal representative. Access for research, quality assurance, audit or educational purposes or by next of kin checking medical history does not constitute access by or on behalf of the patient.No. 1.5.1 Description of records Records of patients/clients of former Crown operated/5th Schedule psychiatric hospitals where the records were wholly or partly created prior to 1960. Disposal action Required as State archives |
No. 1.5.2 Description of records Records documenting the treatment and care of patients/clients under mental health legislation e.g. the Mental Health Act. Disposal action Retain minimum of 45 years after last attendance or official contact or access by or on behalf of the patient, then destroy |
1.6.0 Genetic or inherited disorders
The diagnosis of genetic or inherited disorders.
See Patient/client treatment and care - Hospital and emergency care or Community based health care for records relating to the treatment and care of patients with a genetic or inherited disorder.
| No. | Description of records | Disposal action |
|---|
| 1.6.1 | Records held by specialist genetic units documenting the diagnosis of patients with genetic or inherited disorders. | Retain in agency |
| 1.6.2 | See relevant entry under Patient/client treatment and care for records relating to the management of patients with genetic or inherited disorders. | |
No. 1.6.1 Description of records Records held by specialist genetic units documenting the diagnosis of patients with genetic or inherited disorders. Disposal action Retain in agency |
No. 1.6.2 Description of records See relevant entry under Patient/client treatment and care for records relating to the management of patients with genetic or inherited disorders. Disposal action |
1.7.0 Assisted Reproductive Technology (ART)
The provision of assisted reproductive technology services.
See Patient/client treatment and care - Obstetric/maternal health care for records documenting birth episodes.
| No. | Description of records | Disposal action |
|---|
| 1.7.1 | Records documenting the treatment and care of
assisted reproductive technology (ART) patient/clients. | Retain prescribed information in accordance with
legislative requirements, all
other records retain for minimum of 15 years after last access by or on behalf of the patient, then destroy |
| 1.7.2 | See 1.7.1. | |
No. 1.7.1 Description of records Records documenting the treatment and care of
assisted reproductive technology (ART) patient/clients. Disposal action Retain prescribed information in accordance with
legislative requirements, all
other records retain for minimum of 15 years after last access by or on behalf of the patient, then destroy |
No. 1.7.2 Description of records See 1.7.1. Disposal action |
1.8.0 Sexual assault, physical abuse and neglect patients
The provision of treatment and care to victims of sexual assault, physical abuse and neglect. Includes children, young people, and mandatory reporting cases.
| No. | Description of records | Disposal action |
|---|
| 1.8.1 | Records documenting the treatment and care of victims of: - sexual assault or abuse
- physical abuse and neglect subject to mandatory reporting. This includes instances of the abuse and neglect of children, young people and other vulnerable persons such as the elderly, disabled or persons in care subject to mandatory reporting.
Note: includes records created by: - sexual assault services (including Sexual Assault Assessment Centres which are a Level 1 Sexual Assault Service according to NSW Health Role Delineation Guidelines)
- child protection units/teams
- violence, abuse and neglect services
- child protection counselling services
- JIRT Health workforce
- street services and domestic violence services.
| Adult victims: Retain minimum of 30 years after date of last contact with the service, or request for access or legal event, then destroy Where victims are minors: Retain minimum of 45 years after date of last contact with the service, or request for access or legal event, then destroy |
No. 1.8.1 Description of records Records documenting the treatment and care of victims of: - sexual assault or abuse
- physical abuse and neglect subject to mandatory reporting. This includes instances of the abuse and neglect of children, young people and other vulnerable persons such as the elderly, disabled or persons in care subject to mandatory reporting.
Note: includes records created by: - sexual assault services (including Sexual Assault Assessment Centres which are a Level 1 Sexual Assault Service according to NSW Health Role Delineation Guidelines)
- child protection units/teams
- violence, abuse and neglect services
- child protection counselling services
- JIRT Health workforce
- street services and domestic violence services.
Disposal action Adult victims: Retain minimum of 30 years after date of last contact with the service, or request for access or legal event, then destroy Where victims are minors: Retain minimum of 45 years after date of last contact with the service, or request for access or legal event, then destroy |
1.9.0 Physical abuse and neglect
See Patient/client treatment and care - Sexual assault, physical abuse and neglect patients for records relating to the treatment and care of victims of physical abuse and neglect.
| No. | Description of records | Disposal action |
|---|
| 1.9.1 | See entry 1.8.1 for records relating to the treatment and care of victims of physical abuse and neglect. | |
No. 1.9.1 Description of records See entry 1.8.1 for records relating to the treatment and care of victims of physical abuse and neglect. Disposal action |
1.10.0 Radiotherapy treatment
The delivery of radiation treatment to radiotherapy patients.
| No. | Description of records | Disposal action |
|---|
| 1.10.1 | Records documenting radiation dose delivery to patients undergoing radiotherapy treatment. Includes external radiotherapy, as well as internal radiotherapy (such as radioisotope and brachytherapy). | Where date of death is known: Retain minimum of 15 years after date of death, then destroy Where date of death is not known: Retain a minimum of 15 years after patient would have attained the age of 70 years or after last attendance, whichever is longer, then destroy |
No. 1.10.1 Description of records Records documenting radiation dose delivery to patients undergoing radiotherapy treatment. Includes external radiotherapy, as well as internal radiotherapy (such as radioisotope and brachytherapy). Disposal action Where date of death is known: Retain minimum of 15 years after date of death, then destroy Where date of death is not known: Retain a minimum of 15 years after patient would have attained the age of 70 years or after last attendance, whichever is longer, then destroy |
1.11.0 Electronic health records
Superseded - see relevant patient record or the Normal Administrative Practice provisions of the State Records Act.
1.12.0 Collections or samples of patient significance
See Pre-1930 patient/client records for records created prior to 1930.
| No. | Description of records | Disposal action |
|---|
| 1.12.1 | Collections or samples of patient records identified as being of continuing value for medical or social research purposes. Note: this could include cases where the service has taken a leading role in the development and delivery of new or specialised treatments or because the records: - illustrate or provide comparative insight into the provision of services to particular community groups
- illustrate or provide comparative insight into aspects of treatment, care and the delivery of services over time
- document significant achievements or break throughs in research or relate to research of major national or international significance, interest or controversy
- document significant outbreaks of disease that represented major public health risks and their impact
- document critical points of change or developments in the treatment or management of a particular type of condition, illness or disease
- relate to the diagnosis, management, treatment of or research into particularly rare diseases or conditions and would significantly enhance and contribute to the existing body of knowledge of these diseases or conditions.
| Required as State archives |
No. 1.12.1 Description of records Collections or samples of patient records identified as being of continuing value for medical or social research purposes. Note: this could include cases where the service has taken a leading role in the development and delivery of new or specialised treatments or because the records: - illustrate or provide comparative insight into the provision of services to particular community groups
- illustrate or provide comparative insight into aspects of treatment, care and the delivery of services over time
- document significant achievements or break throughs in research or relate to research of major national or international significance, interest or controversy
- document significant outbreaks of disease that represented major public health risks and their impact
- document critical points of change or developments in the treatment or management of a particular type of condition, illness or disease
- relate to the diagnosis, management, treatment of or research into particularly rare diseases or conditions and would significantly enhance and contribute to the existing body of knowledge of these diseases or conditions.
Disposal action Required as State archives |
1.13.0 Correspondence
Superseded
See Patient/client registration and administration - Patient/client administration for records documenting patient/client contact not recorded elsewhere e.g. copies of service requests or referrals.
See Patient/client treatment and care for correspondence with patients/clients or others on behalf of patients/clients.
See General Retention and Disposal Authority Administrative records Information management - Control for records relating to correspondence logs or registers.
1.14.0 Complaints and incident management
The activities relating to the management of complaints from or incidents involving patients/clients.
See General Retention and Disposal Authority Administrative records Government relations - Advice for records relating to the reporting of critical incidents
See General Retention and Disposal Authority Administrative records Legal services - Litigation for records relating to complaints, incidents or claims that result in legal action and for the handling of subpoenas and discovery orders.
See General Retention and Disposal Authority Administrative records Personnel -Misconduct for records relating to allegations of misconduct against staff, volunteers, work placement students, including allegations of assault against minors.
See General Retention and Disposal Authority Administrative records Personnel - Reporting for records relating to the statutory reporting of incidents or referral of other matters to external bodies such as the Police, Independent Commission Against Corruption, the Ombudsman or child protection agencies e.g. Community Services.
See General Retention and Disposal Authority Public health Services: Administrative records Clinical services - Incident management for records relating to rectification action taken in response to an incident or complaint or the monitoring of complaints and occurrence of incidents
| No. | Description of records | Disposal action |
|---|
1.14.1- 1.14.2 | See the General retention and disposal authority: administrative records Legal services - Litigation. | |
| 1.14.3 | Records relating to the handling of complaints and investigation of incidents concerning the provision of patient/client treatment or care not involving legal action. This includes associated reports of and records of investigations into an incident or complaint. | Retain minimum of 7 years after action completed or until the patient/client attains or would have attained the age of 25, whichever is longer, then destroy For records relating to allegations or cases of child sexual abuse: Retain minimum of 45 years after action completed, then destroy. |
1.14.4- 1.14.5 | See the General retention and disposal authority: administrative records Legal services - Litigation.. | |
| 1.14.6 | Summary records of patient/client complaints, injuries or incidents. | Retain minimum of 30 years after action completed, then destroy |
No. Description of records See the General retention and disposal authority: administrative records Legal services - Litigation. Disposal action |
No. 1.14.3 Description of records Records relating to the handling of complaints and investigation of incidents concerning the provision of patient/client treatment or care not involving legal action. This includes associated reports of and records of investigations into an incident or complaint. Disposal action Retain minimum of 7 years after action completed or until the patient/client attains or would have attained the age of 25, whichever is longer, then destroy For records relating to allegations or cases of child sexual abuse: Retain minimum of 45 years after action completed, then destroy. |
No. Description of records See the General retention and disposal authority: administrative records Legal services - Litigation.. Disposal action |
No. 1.14.6 Description of records Summary records of patient/client complaints, injuries or incidents. Disposal action Retain minimum of 30 years after action completed, then destroy |
1.15.0 Clinical audits
The activities associated with the conduct of clinical audits.
| No. | Description of records | Disposal action |
|---|
| 1.15.1 | Records relating to the conduct of clinical audits for the purpose of evidence based quality management e.g. an audit of the outcome of pain management treatment. | Retain minimum of 5 years after audit completed, then destroy |
No. 1.15.1 Description of records Records relating to the conduct of clinical audits for the purpose of evidence based quality management e.g. an audit of the outcome of pain management treatment. Disposal action Retain minimum of 5 years after audit completed, then destroy |
1.16.0 Medical certificates
Superseded - see entry 2.3.1 for copies of medical certificates issued to patients detailing dates of attendance not maintained as part of the main patient file.
1.17.0 Sterilisation of equipment
The sterilisation of instruments, items and equipment used in surgical and medical procedures.
| No. | Description of records | Disposal action |
|---|
| 1.17.1 | Records relating to the sterilisation of surgical instruments and equipment, e.g. log books, registers. | Retain minimum of 15 years after action completed, then destroy |
| 1.17.2 | Superseded - see 1.17.1. | |
No. 1.17.1 Description of records Records relating to the sterilisation of surgical instruments and equipment, e.g. log books, registers. Disposal action Retain minimum of 15 years after action completed, then destroy |
No. 1.17.2 Description of records Superseded - see 1.17.1. Disposal action |
1.18.0 Surgical procedures
The management of accountable items used in surgical and medical procedures.
See Patient/client registration and management - Patient/client registers for registers of surgically implanted devices or prostheses.
See Patient/client treatment and care - Hospital and emergency care for accountable item and sterile instrument tracking forms which are maintained as part of the patient file.
| No. | Description of records | Disposal action |
|---|
| 1.18.1 | Copies of records of accountable items used in operating theatres e.g. instruments and swab counts. Note: original records are to be maintained as part of the patient file. | Retain minimum of 1 year after action completed, then destroy |
