Health Sector (Clinical Records) Retention and Disposal ......business systems, maps, plans,...

Queensland State Archives Department of Science, Information Technology, Innovation and the Arts

Health Sector (Clinical Records) Retention and Disposal Schedule

Responsible public authority: Health Sector

Queensland Disposal Authority Number (QDAN) 683 Version 1

Date of approval 14 December 2012

Approved by State Archivist Janet Prowse

QSA File Reference QSA12/503

Scope of retention and disposal schedule This schedule covers records created by health sector public authorities that create and manage clinical records. This may include, but is not limited to Hospital and Health Services and Queensland Health. It is not intended to cover private health facilities.

This Schedule is to be used in conjunction with the General Retention and Disposal Schedule for Administrative Records (GRDS).

References to repealed legislation within this Schedule may be taken to be a reference to current legislation if the context permits.

In the event of an administrative change, or the transfer of a function from one public authority to another, this retention and disposal schedule will continue to apply to the records covered by the schedule. For further advice on the currency of approved retention and disposal schedules following administrative change, please contact Agency Services at Queensland State Archives on (07) 3131 7777.

Record Formats This Schedule applies to records created in all formats, unless otherwise specified in the class description. This includes, but is not limited to, records in business systems, maps, plans, photographs, motion picture and records created using web 2.0 media.

http://www.archives.qld.gov.au/Recordkeeping/GRKDownloads/Documents/GeneralDisposalSchedule.pdf

Queensland State Archives Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1

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Authority Authorisation for the disposal of public records is given under s.26 of the Public Records Act 2002 (the Act).

No further authorisation is required from the State Archivist for records disposed of under this schedule. However, the disposal of all public records must be endorsed by the public authority’s Chief Executive Officer, or authorised delegate, in accordance with Information Standard 31: Retention and Disposal of Public Records, and recorded in the public authority’s disposal log.

Public records that are not covered by an approved retention and disposal schedule cannot be disposed of by a public authority.

Disposal of public records not covered by an approved retention and disposal schedule is a contravention of s.13 of the Act. Revocation of previously issued disposal authorities

Any previously issued disposal authority which covers disposal classes described in this retention and disposal schedule is revoked. Queensland Audit Office should take measures to withdraw revoked disposal authorities from circulation. This includes, but is not limited to:

QDAN 546 v.3 issued in August 2007 to Queensland Health

Public records sentenced under revoked retention and disposal schedules should be re-sentenced prior to disposal.

For further advice on the currency of approved retention and disposal schedules, please contact Agency Services at Queensland State Archives on (07) 3131 7777. Retention of records All of the retention periods in this schedule are the minimum period for which the sentenced records must be maintained. Public records cannot be disposed of prior to the expiration of the appropriate retention period. However, there is no requirement for public records to be destroyed at the expiration of a minimum retention period.

Public records must be retained for longer if: i. the public record is or may be needed in evidence in a judicial proceeding, including any reasonably possible judicial proceeding ii. the public records may be obtained by a party to litigation under the relevant Rules of Court, whether or not the State is a party to that litigation iii. the public record must be retained pursuant to the Evidence Act 1977 iv. there is a current disposal freeze in relation to the public record, or v. there is any other law or policy requiring that the public record be retained.

This list is not exhaustive.

Public records which deal with the financial, legal or proprietorial rights of the State of Queensland or a State related Body or Agency regarding another legal entity and any public record which relates to the financial, legal or proprietorial rights of a party other than the State are potentially within the category of public records to which particular care should be given prior to disposal.


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Records which are subject to a Right to Information application are to be retained for the period specified in section 9 – INFORMATION MANAGEMENT of the General Retention and Disposal Schedule for Administrative Records in addition to their required retention period according to an approved retention and disposal schedule. The two periods run concurrently, and may result in a longer required retention period overall. This is in order to cover all appeal and review processes. Even though the records subject to an application may be ready for disposal according to an approved retention and disposal schedule at the time of the Right to Information application, the additional Right to Information retention requirements must still be applied. See section 9 – INFORMATION MANAGEMENT of the General Retention and Disposal Schedule for Administrative Records for records of Right to Information applications.

The disposal of public records should be documented in accordance with the requirements of Information Standard 31: Retention and Disposal of Public Records.

For further advice on the retention and disposal of public records under an approved retention and disposal schedule, please refer to the Queensland State Archives website or contact Agency Services at Queensland State Archives on (07) 3131 7777.

Records created before 1950

Records described in683 v.1 that were created before 1950 should be referred to Queensland State Archives for further appraisal before any disposal action is taken by the public authority. For further advice please refer to the Public Records Brief: Management of Public Records Created Before 1950 which is available from the Queensland State Archives’ website.

Transfer of public records to Queensland State Archives

Records covered by a class with the disposal action of ‘Retain permanently’ should be transferred to Queensland State Archives with the approval of the State Archivist. Records covered by a class with the disposal action of 'Retain permanently by the Queensland Audit Office are not eligible for transfer to Queensland State Archives unless re-appraised and assigned a disposal action of 'Retain permanently'.

Agencies are required to submit a transfer proposal containing details of the records under consideration for transfer. Queensland State Archives will assess the transfer proposal before formal approval to transfer is issued. Please refer to the Guideline on Transferring Public Records to Queensland State Archives available from the Queensland State Archives’ website. The State Archivist reserves the right to revise any previous decisions made with regard to the appraisal and transfer of records. Contact Agency Services at Queensland State Archives on (07) 3131 7777 for further details.



http://www.archives.qld.gov.au/Recordkeeping/PreserveDownloads/Documents/GuideTransferDisposalPublicRecords.pdf

http://www.archives.qld.gov.au/Recordkeeping/PreserveDownloads/Documents/GuideTransferDisposalPublicRecords.pdf


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TABLE OF CONTENTS

1. CLINICAL RECORDS – GENERAL......................................................................................................................................................... 6

Clinical Records – Adults ..............................................................................................................................................................................................6

Clinical Records – Minors .............................................................................................................................................................................................6

Clinical Records – Deceased Minors ............................................................................................................................................................................6

2. CLINICAL RECORDS – EXCEPTIONS ................................................................................................................................................... 7

Clinical Research Records – Adults..............................................................................................................................................................................8

Clinical Research Records – Minors .............................................................................................................................................................................8

Routine clinical worksheets...........................................................................................................................................................................................8

Handover worksheets ...................................................................................................................................................................................................9

Films and other visual material .....................................................................................................................................................................................9

Mental Health Facility Clinical Records – Persons of Special Notification (PSN) .........................................................................................................9

Mental Health Facility Clinical Records – Mental Health Act 1974 – Forensic Patients..............................................................................................10

Notifiable Disease Treatment Records .......................................................................................................................................................................10

Obstetric Records without evidence of Artificial Insemination/In-vitro Fertilisation (IVF) ............................................................................................11

Obstetric Records with evidence of Artificial Insemination/In-vitro Fertilisation (IVF) .................................................................................................11

Artificial Insemination/In-vitro Fertilisation (IVF) Donor Records.................................................................................................................................12

Unborn Child at Risk Notifications...............................................................................................................................................................................12

Organ and Tissue Donors Records.............................................................................................................................................................................12

Pharmacy/Medication Records ...................................................................................................................................................................................12

3. REGISTERS AND INDICES ................................................................................................................................................................... 13

Admission and Discharge Registers ...........................................................................................................................................................................13

Birth Registers.............................................................................................................................................................................................................13


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Death Registers ..........................................................................................................................................................................................................13

Disease and Operation Indexes..................................................................................................................................................................................14

Emergency and Outpatient Attendance Registers ......................................................................................................................................................14

Film and other Visual Material Registers ....................................................................................................................................................................14

Master Patient Indexes (MPI)/Patient Master Indexes (PMI)/Master Patient Registers (MPR) ..................................................................................14

Mental Health Registers..............................................................................................................................................................................................15

Number Registers/Patient Number Registers/Client Number Registers .....................................................................................................................15

Operation/Theatre Registers.......................................................................................................................................................................................15

Short Term Registers ..................................................................................................................................................................................................16

Vaccination Register ...................................................................................................................................................................................................16

Vaccination Register Forms ........................................................................................................................................................................................16

GLOSSARY................................................................................................................................................................................................ 17

SUBJECT INDEX........................................................................................................................................................................................ 18


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1. CLINICAL RECORDS – GENERAL Records displaying evidence of clinical care to an individual or groups of patients/clients. See Section 2 for specific clinical records having different retention periods or special requirements other than those covered by this Section.

Reference Description of records Status Disposal action

1.1 CLINICAL RECORDS – ADULTS Records displaying evidence of clinical care to an individual or groups of adult patients/clients. Excludes clinical record exceptions covered by Section 2 of this Schedule.

Temporary Retain for 10 years after last patient/client service provision or medico-legal action.

1.2 CLINICAL RECORDS – MINORS Records displaying evidence of clinical care to an individual patient/client who is a minor. Includes dental records displaying clinical care provided to children by the Child and Adolescent Oral Health Services (formally known as School Dental Services). Excludes clinical record exceptions covered by Section 2 of this Schedule. See also 1.3 for clinical records of deceased minors and 2.6 for obstetric records.

Temporary Retain for: 10 years from patient/client attaining 18 years of age; AND 10 years after last patient/client service provision or medico-legal action.

1.3 CLINICAL RECORDS – DECEASED MINORS Records displaying evidence of clinical care to an individual patient/client who was a minor and who has deceased prior to attaining adulthood. Includes clinical records related to neonatal deaths where there is no evidence of artificial insemination or in-vitro fertilisation procedures. See 2.6.2 for records of neonatal deaths where there is evidence of artificial insemination or in-vitro fertilisation procedures.

Temporary Retain for: 10 years from date of patient’s/client’s death; AND 10 years after last medico-legal action.


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2. CLINICAL RECORDS – EXCEPTIONS Specific clinical records having different retention periods or other special requirements other than those detailed in Section 1 of this Schedule. Reference Description of records Status Disposal action

2.1 CLINICAL RESEARCH RECORDS Clinical records relating to clinical research (including trials) where: the Health Department has been the investigator and/or the institution in accordance with the Therapeutic Goods Administration’s

(TGA) Note for Guidance on Good Clinical Practice (CPMP/ICH/135/95); and the sponsor has notified the Health Department in writing that the records are no longer required in accordance with Section 5.5.12

of the Therapeutic Goods Administration’s (TGA) Note for Guidance on Good Clinical Practice (CPMP/ICH/135/95). Records comprise the clinical records created before, during and after a clinical trial in accordance with Section 8 of the Therapeutic Goods Administration’s (TGA) Note for Guidance on Good Clinical Practice (CPMP/ICH/135/95), including (but not limited to): Patient/client or subject’s consent for participation Patient/client or subject’s authorisation for use of his/her information from the study Laboratory results Other diagnostics or investigative reports Clinical questionnaires Clinical surveys.


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2.1.1 Clinical Research Records – Adults Clinical research records where the patients/clients or subjects were adults.

Temporary Retain for: 15 years from completion of clinical research/trial; AND 10 years after last patient/client service provision or medico-legal action.

2.1.2 Clinical Research Records – Minors Clinical research records where the patients/clients or subjects were minors.

Temporary Retain for: 15 years from patient/client attaining 18 years of age; AND 10 years after last patient/client service provision or medico-legal action.

2.2 CLINICAL WORKSHEETS

2.2.1 Routine clinical worksheets

Routine clinical worksheets (e.g. daily fluid balance sheets) where the outcome/results are transferred to the patient’s/client’s clinical record.

Temporary Retain until the accuracy of the outcome/results, transferred to the patient’s/client’s clinical record, have been verified.


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2.2.2 Handover worksheets Clinical worksheets and notes made to facilitate the handover and change of shifts.

Temporary Retain until the end of the corresponding shift.

2.3 DIAGNOSTIC IMAGING AND OTHER AUDIO VISUAL MATERIAL Includes diagnostic radiology, nuclear medicine, ultra-sound, computerised tomography, magnetic resonance imaging, and videos.

2.3.1 Films and other visual material Radiographic films or diagnostically equivalent images/material.

Temporary Retain for 5 years after image or recording was made.

2.4 MENTAL HEALTH RECORDS See 1.1 to 1.3 for mental health clinical records not described in 2.4.1 and 2.4.2 below. See 3.9 for Mental Health Registers.

2.4.1 Mental Health Facility Clinical Records – Persons of Special Notification (PSN) Records displaying evidence of clinical care at a mental health facility of an individual patient/client with “Persons of Special Notification (PSN)” status.

Temporary Retain for: 85 years from patient’s/client’s date of birth; AND 10 years after last patient/client service provision or medico-legal action.


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2.4.2 Mental Health Facility Clinical Records – Mental Health Act 1974 – Forensic Patients Records displaying evidence of clinical care at a mental health facility of an individual patient/client with a forensic order made in accordance with the repealed Mental Health Act 1974 where the forensic order expired prior to the implementation of the Mental Health Act 2000.


2.5 NOTIFIABLE DISEASE TREATMENT RECORDS Records displaying evidence of clinical care for the treatment of an individual patient/client for any of the following notifiable diseases: Hepatitis B Hepatitis C HIV Leprosy Q Fever Severe Acute Respiratory Syndrome (SARS) Syphilis Tuberculosis


2.6 OBSTETRIC RECORDS Clinical records related to obstetrics including records related to artificial insemination and in-vitro fertilisation.


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2.6.1 Obstetric Records without evidence of Artificial Insemination/In-vitro Fertilisation (IVF) Records displaying evidence of obstetric care to an individual patient/client where there is no evidence of artificial insemination or in-vitro fertilisation (IVF) procedures. Records may include but are not limted to: clinical records of the mother clinical records of the child. See 2.6.2 for obstetric records where there is evidence of artificial insemination or in-vitro fertilisation (IVF) procedures. See 1.3 for clinical records of neonatal (28 days or less) deaths where there is no evidence of artificial insemination or in-vitro fertilisation (IVF) procedures.

Temporary Retain for: 10 years from the child attaining 18 years of age; AND 10 years after last patient/client service provision or medico-legal action.

2.6.2 Obstetric Records with evidence of Artificial Insemination/In-vitro Fertilisation (IVF) Records displaying evidence of obstetric care to an individual patient/client where there is evidence of artificial insemination or in-vitro fertilisation (IVF) procedures. Records may include but are not limited to: clinical records of the mother; clinical records of the child; clinical records of each other individual or family unit involved in the artificial

insemination or invitro-fertilisation; clinical records related to neonatal (28 days or less) deaths where there is evidence

of artificial insemination or in-vitro fertilisation (IVF) procedures; records relating to consent to treatment, use of semen, ova or embryos and

withdrawal of consent. See 2.6.1 for obstetric records where there is no evidence of artificial insemination or in-vitro fertilisation (IVF) procedures. See 1.3 for clinical records of neonatal (28 days or less) deaths where there is no evidence of artificial insemination or in-vitro fertilisation (IVF) procedures.

Permanent Retain permanently.


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2.6.3 Artificial Insemination/In-vitro Fertilisation (IVF) Donor Records Records relating to information about individual donors involved in artificial insemination or in-vitro fertilisation procedures.


2.6.4 Unborn Child at Risk Notifications Notifications (such as Unborn Child High Risk Alert Forms) received by health facilities from the Department of Child Safety that an unborn child may be at risk of harm, where the patient/client does not present at that facility for delivery. See 2.6.1 and 2.6.2 for notifications where the patient/client presents for delivery.

Temporary Retain for 3 months after expected presentation date.

2.7 ORGAN AND TISSUE DONORS RECORDS Records displaying evidence of clinical care to an individual patient/client who has donated organs/tissues, excluding donations described in Reference 2.6.3 Records may include but are not limited to: clinical records of donors who are adults or minors; clinical records of donors made prior to and after the organ/tissue donation; clinical records of donors where the donation occurs while the patient/client is alive or

after their death; written consents to donate organs made by the patient/client, their parent or their

senior available next-of-kin in accordance with s.10, s.11, s.12B and s.22 of the Transplantation and Anatomy Act 1979.

Temporary Retain for 50 years from last patient/client service provision or medico-legal action.

2.8 PHARMACY/MEDICATION RECORDS Records relating to medication contained in the clinical records of an individual patient/client such as drug or medication orders. Excludes pharmacy records and records of controlled drugs made in accordance with Part 7 of the Health (Drugs and Poisons) Regulation 1996 such as ward drug books, transfer vouchers, etc. Excludes records relating to high cost/highly specialised drugs (HSD) such as eligibility statements, pharmacy registers and usage reports for HSD.

Temporary Retain for 10 years after last patient/client service provision or medico-legal action.


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3. REGISTERS AND INDICES Patient/Client registers and indices including paper-based and electronic registers. Where a single registers is used to document multiple activities, retain for the longest minimum retention period for each individual register. Reference Description of records Status Disposal action

3.1 ADMISSION AND DISCHARGE REGISTERS Registers comprising details of admission and discharge of patients/clients from health facilities such as the admission and discharge dates, name, record number, date of birth or age and sex of the patient/client. Registers may also include admission and discharge times, address, next of kin, admitting diagnosis, discharge outcome (e.g. home, transferred, deceased, etc), and length of stay.


3.2 BIRTH REGISTERS Registers comprising details of births, which occur at health facilities, such as date and time of birth, mother’s name, sex of baby and names of medical and nursing staff in attendance. Registers may also include mother’s record number, age, address and type of birth, status of baby at birth (ie live, stillborn).

Temporary Retain for 120 years after last action.

3.3 DEATH REGISTERS Registers comprising details of deaths of patients/clients that occur at health facilities such as date and time of death, name and record number of patient/client. Register may also include sex, date of birth or age, cause of death and name of medical officer.



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3.4 DISEASE AND OPERATION INDEXES Register/indexes comprising details of patient’s/client’s disease and operations such as patients/clients record number, name, sex, age, date of admission, length of stay, discharge status and destination, responsible Medical Officer or unit, ward, Principal Diagnosis and other diseases or condition, operation and procedure codes related to that admission.


3.5 EMERGENCY AND OUTPATIENT ATTENDANCE REGISTERS Registers comprising details of patient/client attendance at emergency or outpatient facilities such as date and time of attendance, name, sex, date of birth or age of patients/clients, attending medical officer. Registers may also include, record number, address, reason for attendance, and where available, outcome of follow-up arrangements.


3.6 FILM AND OTHER VISUAL MATERIAL REGISTERS Registers comprising details including location of diagnostic film and other visual materials used for tracking purposes and not showing the final disposal of the films. See General Retention and Disposal Schedule for Administrative Records for the retention period for control records.

Temporary Retain until all the film and visual materials described in the register have been disposed of in accordance with Reference Number 2.3.1 of this Schedule.

3.7 MASTER PATIENT INDEXES (MPI)/PATIENT MASTER INDEXES (PMI)/MASTER PATIENT REGISTERS (MPR) Index/registers comprising details which constitutes the patient master index such as the name of the health facility, patient’s/client’s number, name, date of birth, gender, address, and date of patient’s/client’s registration (i.e. the date that record number was assigned).



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3.8 MENTAL HEALTH REGISTERS Registers at health facilities made in accordance with the Mental Health Act 2000 and the repealed Mental Health Act 1974 such as the register of authorised doctors, register of patients liable to be detained, restricted patient registers, seclusion registers, etc. Includes the data sets contained within information systems (such as the Mental Health Information System (MHAIS)) which comprise the registers.


3.9 NUMBER REGISTERS/PATIENT NUMBER REGISTERS/CLIENT NUMBER REGISTERS Registers comprising details which constitute the Number Register such as unit record numbers, patient’s/client’s name, date of birth, gender, and date on which the number was issued.

Temporary Retain until administrative use ceases.

3.10 OPERATION/THEATRE REGISTERS Registers comprising details of patient’s/client’s operations performed at health facilities such as date, serial number of operation, time, patient’s name, sex, age and record number, diagnosis and operative procedure, name of surgeon, assistant surgeon and anaesthetists. Includes register books and data sets contained in electronic registers such as the Operating Room Management Information System (ORMIS).



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3.11 SHORT TERM REGISTERS Registers with the sole purpose of providing information of temporary, short-value (i.e. to assisted in the change of shifts) or information already recorded and available in an acceptable medium (i.e. paper-based or electronic) elsewhere in the public authority (e.g. admission registers). Examples include: Ward Registers – daily cumulative listing of inpatient movement within that ward e.g.

admissions, bed transfers, discharges, etc. Bed Return or Daily Bed Return – daily midnight census for a ward, listing all

inpatients admitted, discharged, transferred, died and those remaining in at midnight. Daily Inpatient Census – listing of all inpatients within a hospital at the time that the

list was created. List may also include current ward of inpatients, visitor access permission and a generic statement in regard to each patient’s general condition.

Temporary Retain until superseded.

3.12 VACCINATION REGISTER Registers comprising details of vaccinations administered in Queensland since July 1993 such as patient’s/client’s name, date of birth, gender, address, telephone number and vaccination information. Includes: Vaccination Record Forms between 1 July 1993 and 30 June 1994; and Data sets contained in electronic registers such as the Vaccination Information and

Vaccination Administration System (VIVAS) since 1 July 1994.


3.13 VACCINATION REGISTER FORMS Vaccination Record Forms documenting the patient’s/client’s details for the vaccination register where the information has been recorded in the vaccination register.

Temporary Retain until the accuracy of data entry into vaccination register has been verified.


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GLOSSARY For definitions of recordkeeping terms, see the Queensland State Archives’ Glossary of Archival and Recordkeeping Terms available via Queensland State Archives’ website (www.archives.qld.gov.au).

Clinical Record

As per the Queensland Health Position Statement on Clinical Records, August 2002, the term Clinical Record will be used to describe those records that contain data or information relating to individual patient’s/client’s (or groups of patients/clients) created to evidence the delivery of a clinical service.

Examples of public records considered by Queensland Health to be clinical records include: Admission/discharge forms; History/referral information; Examination reports; Pathology/diagnostic records; Interpretive reports; Reports of treatment provided; Obstetric records; Drug/medication orders and administrations; Imaging records, photographs, audiovisual materials; Signed patient/client consent forms; Copies of statutory health reports and notifications where the original document

has been forwarded to the governing body; Examples include records fulfilling obligations under the Births, Deaths and

Marriages Registration Act 2003 and Coroners Act 2003; Maintenance and sterilisation records of clinical equipment that are linked to one

Unit Record Number (URN) and relates to the provision of a clinical service eg. Sterilisation Production Record (linked to a patient).

Examples of public records not considered by Queensland Health to be clinical records include: Clinical Ward/Unit/Divisional management records

including statistical reports; Scientific Services records inclusive of forensic science

and public health science records; Personnel records of medical, nursing and allied health

staff; Clinical equipment maintenance records and sterilisation

records that are not linked to a URN and do not relate to the provision of a clinical service;

Patient billing records; Patient Travel Subsidy Scheme records and patient

transport records; Patient complaints; Clinical Trial records held by a clinical trial

coordinator/data custodian; Clinical Research records held by clinical research teams; Mental Health Act Forms

Note: The records not considered clinical records are still public records and must not be disposed of without authorisation from the State Archivist in accordance with s.13 of the Public Records Act 2002.


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SUBJECT INDEX

Note: References to the QDAN 614 in the index refer to the Queensland Health (Pathology Laboratory Records) Retention and Disposal Schedule (QDAN 614).

admission registers.......................................13

artificial insemination

clinical records ..........................................11

consent to treatment .................................11

donor records............................................12

attendance registers (emergency / outpatient)..................................................................14

audiovisual clinical records.............................9

bed returns (daily).........................................16

birth registers................................................13

child safety (unborn child high risk alert forms)..................................................................12

children ........................................... see minors

client number registers .................................15

clinical

records (general)

adults.......................................................6

minors......................................................6

research ......................................................7

adults....................................................... 8

minors ..................................................... 8

trials ............................................................ 7

adults....................................................... 8

minors ..................................................... 8

worksheets

handover ................................................. 9

routine ..................................................... 8

consents

artificial insemination / in-vitro fertilisation (IVF) ...................................................... 11

clinical research / trials ............................... 7

organs / tissue donations (Transplantation and Anatomy Act 1979)......................... 12

CPMP/ICH/135/95 (clinical research / trials) .. 7

daily bed returns........................................... 16

daily fluid balance sheets ............................... 8

daily inpatient census................................... 16

death registers.............................................. 13

deaths of minors (clinical records)

general ........................................................6

neonatal.......................................................6

artificial insemination / in-vitro fertilisation (IVF) ...................................................11

diagnostic films ...............................................9

registers.....................................................14

diagnostic films / images.................................9

diagnostic radiology (images) .........................9

discharge registers........................................13

disease registers / indexes ...........................14

donor records

artificial insemination / in-vitro fertilisation (IVF).......................................................12

organs / tissues .........................................12

drug orders (clinical records) ........................12

embryos (use of in artificial insemination / in-vitro fertilisation) ........................................11

emergency attendance registers...................14


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films (diagnostic).............................................9

registers ....................................................14

forensic orders (Mental Health Act 1974) .....10

handover worksheets / notes..........................9

Health (Drugs and Poisons) Regulation 1996

transfer vouchers / ward drug books.........12

hepatitis B (treatment records) .....................10

hepatitis C (treatment records) .....................10

highly specialised drugs (HSD) ....................12

HIV (treatment records) ................................10

HSD (highly specialised drugs) ....................12

images (diagnostic) ........................................9

indexes

diseases....................................................14

master patient ...........................................14

operations .................................................14

patient master ...........................................14

inpatient census (daily) .................................16

in-vitro fertilisation (IVF)

clinical records ..........................................11

consent to treatment .................................11

donor records............................................ 12

IVF (in-vitro fertilisation)

clinical records .......................................... 11

consent to treatment ................................. 11

donor records............................................ 12

leprosy (treatment records) .......................... 10

magnetic resonance imaging ......................... 9

master patient indexes (MPI) ....................... 14

master patient registers (MPR) .................... 14

medication orders (clinical records).............. 12

mental health (clinical records)

adults .......................................................... 6

forensic orders .......................................... 10

minors ......................................................... 6

Persons of Special Notification (PSN) ........ 9

registers .................................................... 15

Mental Health Act 1974

forensic orders .......................................... 10

registers .................................................... 15

Mental Health Act 2000

registers .................................................... 15

Mental Health Information System (MHAIS) .15

minors (clinical records)

clinical research / trials ................................8

deceased minors .........................................6

general ........................................................6

organ / tissue donors.................................12

neonatal deaths (clinical records) ...................6

artificial insemination / invitro-fertilisation (IVF).......................................................11

notes (handover).............................................9

notifiable diseases (treatment records).........10

nuclear medicine (diagnostic images).............9

number registers ...........................................15

obstetrics

clinical records...........................................11

artificial insemination / in-vitro fertilisation (IVF) ...................................................11

donor records ............................................12

Operating Room Management Information System (ORMIS) .......................................15

operation registers ........................................15

operation registers / indexes.........................14


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organ donors (clinical records) .....................12

outpatient attendance registers ....................14

ova (use of in artificial insemination / in-vitro fertilisation)................................................11

pathology

reports within clinical records......................6

patient master indexes (PMI)........................14

patient number registers...............................15

Persons of Special Notification (PSN) ............9

pharmacy records.........................................12

Q Fever (treatment records) .........................10

questionnaires (clinical research / trials).........7

radiographic films ...........................................9

radiology (diagnostic images).........................9

registers

admission..................................................13

attendance (emergency / outpatient) ........14

birth ...........................................................13

client number ............................................15

death .........................................................13

discharge ..................................................13

diseases....................................................14

emergency attendance ............................. 14

films / visual materials............................... 14

master patient ........................................... 14

mental health ............................................ 15

number...................................................... 15

operations........................................... 14, 15

outpatient attendance ............................... 14

patient number.......................................... 15

short term.................................................. 16

theatre....................................................... 15

vaccination................................................ 16

ward.......................................................... 16

reports

clinical research / trials ............................... 7

pathology (within clinical records)............... 6

research (clinical) ........................................... 7

adults .......................................................... 8

minors ......................................................... 8

SARS (treatment records) ............................ 10

school dental program (clinical records)......... 6

semen (use of in artificial insemination / in-vitro fertilisation)........................................ 11

severe acute respiratory syndrome (SARS) (treatment records)....................................10

shifts (handover worksheets / notes ...............9

short term registers .......................................16

surveys (clinical research / trials)....................7

syphilis (treatment records)...........................10

theatre registers ............................................15

Therapeutic Goods Administration (TGA)

Note for Guidance on Good Clinical Practice (CPMP/ICH/135/95).................................7

tissue donors (clinical records) .....................12

tomography (diagnostic images).....................9

transfer vouchers (Health (Drugs and Poisons) Regulation 1996) .......................................12

Transplantation and Anatomy Act 1979

consents to donate organs / tissues..........12

trials (clinical) ..................................................7

adults...........................................................8

minors..........................................................8

tuberculosis (treatment records) ...................10

ultra-sound (diagnostic images)......................9

unborn child high risk alert forms ..................12


of 21

Vaccination Information and Vaccination Administration System (VIVAS) ................16

vaccination register / forms...........................16

videos (clinical records) ..................................9

visual materials (registers) ........................... 14

VIVAS (Vaccination Information and Vaccination Administration System) ......... 16

ward drug books (Health (Drugs and Poisons) Regulation 1996) ...................................... 12

ward registers ...............................................16

worksheets (clinical)

handover .....................................................9

routine .........................................................8

Health Sector (Clinical Records) Retention and Disposal ......business systems, maps, plans,...

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Transcript of Health Sector (Clinical Records) Retention and Disposal ......business systems, maps, plans,...