Part 2: Understanding and using the authority (GDA17)

2.1 Overview

Purpose

The purpose of issuing the General Retention and Disposal Authority - Public Health Services: Patient/Client records is to permit public health services and facilities to destroy certain health care records of patients and clients, after appropriate minimum retention periods have been met, and to identify which patient/client records are required as State archives.

Previous disposal authorisations superseded

This retention and disposal authority supersedes previous disposal authorisation in the following authority:

Changes to retention periods to note:

What records does this authority cover?

This Authority authorises the disposal of:

• records relating to the treatment and care of individual patients and clients within the NSW public health system, including records of allied health care services and research participants
• patient administration registers, systems and databases used to record summary information about patients and clients
• records relating to diagnostic imaging and pathology and laboratory services
• records relating to the supply and administration of pharmaceuticals, encompassing drugs, poisons and other substances
• records of notifications to prescribed bodies concerning patient medical conditions
• records relating to the management of patient and client finance and property during the period of their admission to a facility or service.

Date range of records covered

Patient/client records listed in this authority created wholly or in part prior to 1930 are required as State archives (see also 2.3 Records required as State archives below). For records created wholly after 1930 the minimum retention periods and disposal actions identified in this authority apply to the various classes of records listed.

What records are not covered

This Authority does not cover records relating to the management and administration of public health organisations. Services should consult the following for disposal authorisation.

How long is this authority in force?

This authority will remain in force until it is superseded by a new authority or it is withdrawn from use by State Records.

Providing feedback

To suggest amendments or alterations to this Authority please contact us.

Further assistance

To obtain assistance in the interpretation or implementation of this Authority, or any of our general retention and disposal authorities, contact us.

2.2 Guidelines for implementation

Introduction

Comprehensive information about implementation of disposal authorities is found in State Records' guideline on sentencing records, guideline on destruction of records and procedures for transferring records to State Records custody.

Minimum retention periods

The Authority specifies minimum retention periods for all records not required as State archives. A Service must not destroy or otherwise dispose of records before the minimum retention period has expired. Services may retain records for longer periods of time, subject to organisational need, without further reference to State Records. Reasons for longer retention can include legal requirements, administrative need, on-going research use or government directives.

Retention of electronic records

Electronic records must be protected and readily accessible for the specified minimum retention period. See Managing digital records for information relating to managing the accessibility of electronic and other technology dependent records.

Destroying records

When the authorised minimum retention period has been reached, appropriate arrangements for the destruction of records can be made. Destruction of records in accordance with the Authority may be undertaken without further reference to State Records, unless otherwise advised. Persons using the Authority should apply it with caution, bearing in mind that the authorisations for disposal are given in terms of the State Records Act only. It is the responsibility of the public office to ensure that all legal and other requirements for retention of records have been met before disposing of any of its records. A public office must not destroy any records where the public office is aware of possible legal action, investigation or inquiry where the records may be required as evidence.

Transferring records required as State archives

Records identified in the Authority as being required as State archives should be prepared for transfer to State Record's custody and/or control only when they are no longer required for ongoing business use.

Transfer of ownership must be authorised

Regardless of whether a record has been authorised for destruction or is required as a State archive, a public office must not transfer ownership of a State record to any person or organisation without the explicit authorisation of State Records.

2.3 Records required as State archives

Introduction

Records which are to be retained as State archives are identified with the disposal action Required as State archives.

Pre 1930 records

Patient/client records listed in this authority created wholly or in part prior to 1930 are required as State archives (for example a file started in 1913 and ending shortly after 1930). Prior to proposing to transfer pre 1930 records as State archives services should contact State Records to discuss the condition, types, content and quantities of records involved. Some records may be subject to further appraisal if State Records does not consider their retention as State archives is warranted.

Identifying significant and unique records

The provisions relating to significant or unique collections of patient records (see 1.12.0) are included for special exceptions that may arise from time to time. Individual services may identify exemplary or significant collections of records amongst their holdings that warrant ongoing retention as State archives. This may be because 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 in research 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

This may encompass records relating to a particular time period or to the treatment of a particular illness or condition or records of a specific service, facility or research project.

Services that think that they hold records of significance should contact State Records.

2.4 Records that have been imaged

This authority authorises the destruction of the originals of health care records that have been imaged provided that:

• the records are not State archives that were received or created prior to January 1, 2000
• the records are not of a class listed in the 'Exclusions' section of the General Retention and Disposal Authority - Imaged records (GDA 24)
• all requirements for retaining originals have been assessed and fulfilled
• copies are made which are authentic, complete and accessible
• copies are kept for the authorised retention period, and
• originals are kept for quality control purposes for an appropriate length of time after copying.

See Managing digital records for information relating to managing the accessibility of technology dependent records and Recordkeeping in Brief 11: Digital imaging and recordkeeping for guidance concerning the use of imaging technologies.