Part 1: The General Retention and Disposal Authority (GDA17)
This authority applies to any organisation, facility or service which is part of the New South Wales public health system.
1.1 Statement of authority | 1.2 Scope of patient/client health care records | 1.3 Quick reference to classes of records covered | 1.4 Records authorised for disposal
1.1 Statement of authority
| GDA No | GDA 17 |
|---|---|
| Public office | This authority applies to any organisation, facility or service which is part of the New South Wales public health system. |
| Scope | This general retention and disposal authority covers records documenting the provision of health care to patients and clients of the public health system. |
| Authority | This general retention and disposal authority is issued under section 21(2)(c) of the State Records Act. It has been approved by the Board of the State Records Authority in accordance with section 21(3) of the State Records Act. |
| Authorised | 19 May 2004 |
1.2 Scope of patient/client health care records
Patient and client health care records document an individual's health evaluation, diagnosis, treatment, care, progress and health outcome. These records should be created and maintained in accordance with:
- the principles outlined in NSW Department of Health Circular No 98/59 Principles for the creation, management, storage and disposal of health care records
- policies and procedures contained in the Department's Patient Matters Manual and Health Records and Information Manual for Community Health Facilities
- any guidelines or directives that may be issued by the Department from time to time.
Records relating to the provision of treatment and care to a patient/client include (but are not limited to) records relating to or of a patient's/client's:
- admission, including medical and nursing records
- history (medical and social of the patient or their family)
- examination results (physical or other)
- transfer, referral or assessment documentation
- correspondence between the patient or their representative and the health care service
- consultation reports (medical or other)
- principal diagnosis and any other significant diagnosis
- medication or drug orders and medication administered or prescribed (including oral, parenteral and incident reports)
- nursing care (including all versions or revisions of nursing care plans) and clinical pathways observations
- counselling, allied health, social work or other health care professional notes
- allergies or special conditions
- doctor's or physician's orders
- all observations and progress notes (including those recorded on separate sheets)
- problem lists (master or other)
- requests for and results or reports of all laboratory, diagnostic or investigative tests or procedures performed (including pathology, X-ray or other medical imaging examinations)
- consent or authority to carry out any treatment, procedure or release of information and certification that consent is informed (including removal or donation of tissue or organs, consent to special procedures etc. See also NSW Health Department Circular No 99/16 Patient information and consent to medical treatment)
- refusal of treatment or withdrawal of consent
- prenatal, obstetric, newborn and perinatal treatment, care and outcomes (includes newborn records and perinatal morbidity statistics)
- surgical procedure or operation (including pre-operative checklists, anaesthetic records and peri operative nurses reports including instrument and swab count records and post operative observations)
- all therapeutic treatments or procedures (including anti-coagulant, diabetic, dialysis, electric shock therapy (EST) and electro convulsive therapy (ECT))
- statements made for the Police and Coronial Inquest Reports
- discharge (includes final diagnosis, operative procedures, summary or letter of discharge and discharge at own risk or against advice)
- death (includes autopsy or post-mortem reports).
1.3 Quick reference to classes of records covered
1.4 Records authorised for disposal
1.0.0 Patient/client treatment and care
2.0.0 Patient/client registration and identification
3.0.0 Patient diagnosis - imaging services
4.0.0 Patient diagnosis - pathology and laboratory services
5.0.0 Pharmaceutical supply and administration
