Part 1: The General retention and disposal authority

1.1 Statement of authority

Two pdf versions of the 2019 authority as well as a separate index have been developed - one contains justifications for the disposal actions:

• GDA17 2019 revision (updated October 2020)
• GDA17 2019 revision with justifications
• GDA17 index

1.2 Schedule of amendments and justifications

GDA17 was originally issued in 2004 with a number of minor amendments in 2006, 2009 and 2011. In 2019 the entire authority was reviewed. For further information see:

• Schedule of 2019 amendments, including no changes to disposal action, changes to disposal action and scope; and entries removed. 
• Linking table GDA17 (2004 version) to GDA17 (2019 version).

1.3 Resentencing

The amendments to GDA17 do not affect records that have already been destroyed or transferred as State archives. However, where minimum retention periods have changed and the records have been sentenced, local health districts will need to ensure that the correct disposal action has been applied to the records. The linking tables above will assist with this process.

Part 2: Understanding, using and implementing the authority

The purpose of this general retention and disposal authority is to identify those records created and maintained by NSW public offices providing health care which are required as State archives, and to provide approval for the destruction of certain other records  after minimum retention periods have been met. The approval for disposal given by this authority is given under the provisions of the State Records Act 1998 only and does not override any other obligations of an organisation to retain records.

The records retention and disposal practices outlined in this authority are approved under section 21(2)(c) of the State Records Act 1998 (NSW). Part 3 (Protection of State Records) of the Act provides that records are not to be disposed of without the consent of the State Archives and Records Authority of New South Wales (NSW State Archives and Records) with certain defined exceptions. These exceptions include an action of disposal which is positively required by law, or which takes place in accordance with a normal administrative practice (NAP) of which NSW State Archives and Records does not disapprove. Advice on the State Records Act can be obtained from NSW State Archives and Records.

The authority sets out how long the different classes of records generated by an organisation must be kept to meet its legal, operational and other requirements, and whether the records are to be kept as State archives.

NSW State Archives and Records’ decisions take into account both the administrative requirements of public offices in discharging their functional responsibilities and the potential research use of the records by the NSW Government and the public. One of NSW State Archives and Records’ functions is to identify and preserve records as State archives. These are records which document the authority and functions of Government, its decision-making processes and the implementation and outcomes of those decisions, including the nature of their influence and effect on communities and individual lives. Criteria for the identification of State archives are listed in Building the Archives: Policy on records appraisal and the identification of State archives. The Policy also explains the roles and responsibilities of NSW State Archives and Records and of public offices in undertaking appraisal processes and disposal activities.

Public offices authorised to use this authority
This general retention and disposal authority applies to:

• any organisation, facility or service which is part of the New South Wales public health system, including the local health districts and the NSW Ambulance Service.
• NSW public offices who provide health care services to clients, such as NSW universities.

What records does the 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 relating to the provision of allied health care and to research participants
• records relating to the treatment and care of individual patients and clients by other relevant NSW public offices, such as universities, including records relating to the provision of allied health care and to research participants
• patient/client administration registers, systems and databases used to record summary information about patients and clients
• records relating to diagnostic imaging and pathology and laboratory services, with the inclusion of permission to destroy certain records as per relevant legislative requirements and/or national standards and guidelines (for example standards and guidelines issued by the National Pathology Accreditation Advisory Council or its successor agency/ies)
• 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/client finances and property during the period of their admission to a facility or service
• records relating to the management of clinical and non-clinical research, trials or studies, etc.

What records are not covered
This Authority does not cover:

• records relating to the management and administration of public health organisations. See the General retention and disposal authority: Public health services administrative records (GDA21)
• records relating to general administration (ie not health sector specific), financial management and personnel are covered by the General retention and disposal authority: administrative records (GA28)
• records relating to the provision of State  wide health services such as those provided by the Clinical Excellence Commission, the Bureau of Health Information, The Health Education Training Institute and the Agency for clinical innovation. See Health Services: statewide health services, quality assurance, reporting, education and training (GA44).

Records of private hospitals, services, nursing homes, centres etc. are not State records and are not covered in this disposal authority. They should be retained and disposed of in accordance with any requirements of the Act or regulations under which the establishment is licensed.

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 NSW State Archives and Records.

Previous disposal authorisations superseded
This disposal authority supersedes previous disposal authorisation in the following authority:

• certain parts of the General retention and disposal authority: public health services patient records, 2004 version. See Linking table GDA17 (2004 version) to GDA17 (2019 version) for details of amendments to the authority..
• The General retention and disposal authority: university records, with respect to health services (GDA23, entries 14.0.0.).

Records covered by normal administrative practice (NAP)
Certain records of a facilitative, ephemeral or duplicate nature can, in prescribed circumstances, be disposed of in accordance with the normal administrative practice (NAP) provisions of the State Records Act without the need of formal approval from NSW State Archives and Records. See Schedule 2 of the State Records Regulation 2015 for further information on what constitutes normal administrative practice in a public office.

Public offices should develop internal policies and procedures, based on Schedule 2 of the Regulation, to define and authorise what is meant by normal administrative practice for their organisation and to identify and document the types of records that are disposed of under this provision of the Act as part of the routinely implemented practices of the organisation.

Providing feedback
To suggest amendments or alterations to this authority please contact us via email at: govrec@records.nsw.gov.au or phone (02) 9673 1788.

Further assistance
NSW State Archives and Records provides guidance in the use of retention and disposal authorities as well as other aspects of records management. More information is available on our website at www.records.nsw.gov.au/recordkeeping. To obtain assistance in the interpretation or implementation of this authority, or any of our general retention and disposal authorities, contact us at: govrec@records.nsw.gov.au or phone (02) 9673 1788.

Implementing the authority

This general retention and disposal authority covers records controlled by the public office and applies only to the records or classes of records described in the authority. The authority should be implemented as part of the records management program of the organisation. Two primary objectives of this program are to ensure that records are kept for as long as they are of value to the organisation and its stakeholders and to enable the destruction or other disposal of records once they are no longer required for business or operational purposes.

The implementation process entails use of the authority to sentence records. Sentencing is the examination of records in order to identify the disposal class in the authority to which they belong. This process enables the organisation to determine the appropriate retention period and disposal action for the records. For further advice see Implementing a retention and disposal authority.

Where the format of records has changed (for example, from paper-based to electronic) this does not prevent the disposal decisions in the authority from being applied to records which perform the same function. The information contained in non paper-based or technology dependant records must be accessible for the periods prescribed in the classes. Where a record is copied, either onto microform or digitally imaged, the original should not be disposed of without authorisation (see the General Retention and Disposal Authority – Original or source records that have been copied). Public offices will need to ensure that any software, hardware or documentation required to gain continuing access to technology dependent records is available for the periods prescribed.

Minimum retention periods

The authority specifies minimum retention periods for all records not required as State archives. A public office must not destroy or otherwise dispose of records before the minimum retention period has expired. If a public office desires to reduce the minimum retention period it must seek specific written approval from NSW State Archives and Records. Public offices may retain records for longer periods of time, subject to organisational need, without further reference to NSW State Archives and Records.

Records required as State archives

Records which are to be retained as State archives are identified with the disposal action 'Required as State archives'. Records that are identified as being required as State archives should be stored in controlled environmental conditions and control of these records should be transferred to NSW State Archives and Records when they are no longer in use for official purposes.

Transferring records identified as State archives and no longer in use for official purposes to NSW State Archives and Records should be a routine and systematic part of a public office's records management program. If the records are more than 25 years old and are still in use for official purposes, then a 'still in use determination' should be made.

To obtain assistance regarding transferring material as State archives, contact the Senior Archivist, Transfer/Custody at: transfer@records.nsw.gov.au or (02) 9673 1788.

Records approved for destruction

Records that have been identified as being approved for destruction may only be destroyed once a public office has ensured that all other requirements for retaining the records are met. Retention periods set down in this authority are minimum periods only and a public office should keep records for a longer period if necessary. Reasons for longer retention can include legal requirements, administrative need, government directives and changing social or community expectations. A public office must not dispose of any records where the public office is aware of possible legal action (including legal discovery, court cases, formal applications for access) where the records may be required as evidence.

Once all requirements for retention have been met, destruction of records should be carried out in a secure and environmentally sound way. Relevant details of the destruction should be recorded. See Destruction of records.

Regardless of whether a record has been approved for destruction or is required as a State archive, a public office or an officer of a public office must not permanently transfer possession or ownership of a State record to any person or organisation without the explicit approval of NSW State Archives and Records.

Records required to be retained in agency

There are a number of entries where the disposal action is retain in agency. There is no authorisation for destruction of these records – they must be maintained on an ongoing basis.

Transfer of ownership must be approved

Regardless of whether a record has been approved 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 NSW State Archives and Records. This does not apply to transfers to other NSW public offices such as another local health district or the Ministry of Health.

Retention of digital records

Digital records must be protected and readily accessible for the specified minimum retention period.

Imaged records

Many public offices routinely image records. This may be the scanning of incoming correspondence or bulk digitisation of existing hard copy records such as patient files. Most hard copy originals are authorised for destruction after imaging, provided a number of conditions are met. Public offices should check General retention and disposal authority: original or source records that have been copied for more information.

Interpretation of disposal triggers in this authority

It is very important that triggers are appropriately interpreted and understood by those implementing the authority. Sometimes they rely on information from elsewhere in the organisation. Where possible, the organisation should build the recording of the dates or required information into standard records procedures so staff will know, for example, when a file should be marked as inactive or closed. Without this information being recorded, sentencing cannot take place in a streamlined or efficient manner.

• After last attendance or official contact or access by or on behalf of the patient: 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.

• Until patient attains or would have attained the age of 25 years: This requires patient/client records to be retained until the patient attains, or would have attained (in cases where the date of birth of not known or the patient dies), until the age of 25 is reached.

• In accordance with the relevant legislative requirements and/or national standards and guidelines: In some cases the retention of records is mandated by legislation or standards, for example, the National Pathology Accreditation Advisory Council standards or the Assisted Reproductive Technology Act 2007. Where specified in the disposal authority these instruments should for the disposal of records.

• After action completed: This is the most common disposal trigger in the authority. 'Action completed' refers to the final transaction of business, i.e. the final document is attached to the file and the file is closed. An action does not include a file movement or audit (unless the organisation determines an audit is an action). In the case of paper-based registers the date of the last entry in the register may be a suitable trigger for when action is completed (providing all actions associated with the matters recorded in the register have been completed). In the case of electronic registers, however, it may be more appropriate to apply the disposal action to individual entries in the register rather than the register as a whole (as the last action on the register as a whole may be indefinite). In this case the trigger can be calculated from the last time an individual entry in the register was updated or amended, or from when the data has become obsolete (i.e. when all the business for which the record was maintained has been completed).

• Until ceases to be of administrative or reference use: This trigger usually applies where ongoing use of the records is likely to be short term, or where ongoing reference use of the records is linked to the conduct of business processes and the determination of appropriate periods for retention relies on an organisation's assessment of its own business needs and uses. This can vary from one organisation to another depending on the nature of its business. For the purposes of implementing the authority and facilitating the production of reports or triggers for the review of these records as part of a regular disposal program the organisation may wish to define a standard retention period for these types of records. Suitable standard retention periods can be defined through discussions with business units or action officers who use the records.

• Whichever is longer: Please note that for some entries, the minimum disposal action is qualified by the term ‘whichever is longer’ e.g. entry 1.1.1: Retain minimum of 15 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. This means it is not just a case of 15 years after last attendance, or until they reach the age of 25. If a 17 year old is admitted their record will not be eligible for destruction until they reach the age of 32 (depending on the length of the stay).

Patients with more than one patient file

Public health services may be managing hybrid systems where there are paper and digital records for the same patient. In some cases, it is not possible to identify if an earlier file relates to an existing patient because of common names, changes of address or insufficient recording of details. Some of these files may have been inherited from another health provider with very little in the way of listing or control systems.

For admitted patients, it is best practice to retain records relating to the same patient as if they were part of the same record, and not to destroy any parts until the minimum retention period for the later admission has been reached. It is not always possible to determine whether a previous file will be relevant or not for the current care of a patient, and they may show a pattern of incidents - this is especially so for vulnerable patients.

However, if the case files have reached the minimum retention period, and they do not relate to a current patient, or it is not actually possible to tell if they relate to a current patient, health services should institute the normal internal approval processes to destroy the records. Retaining patient records beyond what they are required for clinical purposes, or for longer than the minimum retention periods set out in this authority, could be a breach of privacy legislation.

This advice relates primarily to patients who are admitted to hospitals (entries 1.1.1 and 1.1.2). In cases where an admitted patient has also attended outpatients clinics or community – based health care, a risk assessment should be conducted to confirm whether it is appropriate to apply the lesser retention period.

Managing the calculation of triggers and disposal processes

Public offices need to consider and plan how they are to manage the implementation of triggers. For some it may be possible to automate the process. For example, a date of birth may be entered into the public office's system and automatically applied as a 'after date of birth' trigger in the records management system.

If automation is not possible, the development of business rules or procedures may be required to ensure that information is communicated by the relevant business unit to the records management unit so that the trigger is applied.

When disposal dates have been reached, procedures should also be in place to ensure the circulation of lists or details of records proposed for destruction to relevant action officers for internal authorisation and approval before any disposal action takes place. These officers can identify if circumstances have changed, e.g. extensions of contracts or legal cases, which will affect the implementation of disposal decisions and may warrant the retention of records for longer periods as appropriate.

Part 3: The Authority

PATIENT/CLIENT TREATMENT AND CARE (1.0.0)

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 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.

First published 2004/Revised 2006 (entry 9.1.1 and Guidelines section 2.4)/Revised 2009 (Guidelines section 2.1)/ Revised 2011 (additional guidance in entry 1.5.2)/Revised 2019 (multiple entries)