Records Disposal Schedule For ACT Health Clinical Records

CHHS18/098
Canberra Hospital and Health Services

Operational Procedure
Records Disposal Schedule for ACT Health Clinical Records
Contents
Contents......................................................................................................................................1
Purpose.......................................................................................................................................2
Alerts...........................................................................................................................................2
Scope...........................................................................................................................................3
Guide to using this document.....................................................................................................3
Section 1 – Patient/Client Registration and Identification.........................................................4
Section 2 – Treatment and Care Records...................................................................................7
Section 3 – Patient Diagnosis – Imaging Services.....................................................................16
Section 4 – Patient Diagnosis – Pathology and Laboratory Services........................................17
Section 5 – Pharmaceutical Supply and Administration...........................................................21
Section 6 – Notifications – Data Collection...............................................................................22
Section 7 – Patient Finance and Property Management..........................................................23
Section 8 – Research Management..........................................................................................24
Section 9 – Digitised Records (duplication/scanning)..............................................................26
Section 10 – Normal Administrative Practice (NAP) Records...................................................27
Section 11 – Summary of the Destruction Process...................................................................27
Implementation........................................................................................................................28
Related Policies, Procedures, Guidelines and Legislation........................................................28
Definition of Terms...................................................................................................................29
Search Terms.............................................................................................................................30
Appendices................................................................................................................................31
Appendix A – TRO Records Disposal Concurrence Form......................................................32
Appendix B – Index...............................................................................................................34
Doc Number Version Issued Review Date Area Responsible Page

CHHS18/098 1 15/03/2018 01/04/2022 CSS – Clinical 1 of 36
Records
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
CHHS18/098
Purpose
The purpose of this document is to present the detail contained in the approved Territory
Records Office (TRO) - Health Treatment and Care - Records Disposal Schedule in a more
useable format for ACT Health staff. This document in itself does not provide the legal
authority to destroy ACT Government records, but it does reference the Disposal Class
numbers from the approved Disallowable Instrument so can be reliably used as a guide
when sentencing Health Records.
This document has been developed in accordance with the Territory Records (Records
Disposal Schedule – Health Treatment and Care Records) Approval 2017 (No 1) – Notifiable
instrument NI2017—629.
Back to Table of Contents

Alerts
The retention periods specified in this document are minimum retention periods only and
records can be kept for a longer period if considered necessary for business requirements.
Territory Records Office (TRO) approval is required prior to any sentencing and destruction
of ACT Health clinical records by submission of a Records Disposal Concurrence Form
(Appendix A) completed by the Director Clinical Records Services in consultation with the
Business Area.
Staff must not dispose of any records where they are aware of possible legal action for which
the records may be required as evidence or if there is a current records disposal freeze in
effect. Information regarding current records disposal freezes can be obtained from the
ACT Government Territory Records Office.
To confirm if legal action is pending contact the Medico Legal Coordinator, Clinical Safety
and Quality Unit on 6205 6955 or the Manager of the Insurance and Legal Liaison Unit on
6205 0928.
Advice from the ACT Government Solicitor in 2016 indicated that where the Division or
Service can be defined as “an entity” under the Health Records (Privacy and Access) Act 1997
their records can be destroyed in accordance with the Territory Records Disposal Schedule
for Health Treatment and Care Records which can be found on the ACT Legislation Register.

Records
CHHS18/098
Scope
This document applies to all health records created or maintained by ACT Health and applies
to records in any format, including paper records, electronic records, photographs, visual or
audio recordings etc. It pertains to all ACT Health staff who are involved in the creation, use,
management and disposal of health records.
If a patient’s clinical record contains documentation from more than one record category,
always apply the longest relevant retention period to the entire record.

Guide to using this document
This document is divided into tables for each category of records, as per the index, to
facilitate logical grouping of the TRO record classes into clinically relevant categories and
specific types of health record. The tables also reference the administrative record classes
from the TRO RDS.
This alternate grouping retains the Disposal Class Entry Numbers (or TRO Ref No.) while
conforming to national health information management principles, to assist in sentencing
health records in a clinical setting. To ensure synchronisation, this document can only be
modified/updated in conjunction with the approved TRO Records Disposal Schedule i.e.
Territory Records (Records Disposal Schedule – Health Treatment and Care Records)
Approval 2017 (No 1) – Notifiable instrument NI2017—629.
Section Heading: 1. Functional Record Category

Functional record category 0 e.g. Patient Registration or Treatment and Care
(different coloured section
denotes different functional Summary detail pertaining to overall record category
category or broad record type)
Item Number Record Description Disposal
RDS table: Type Action
TRO Ref No.
Record Disposal Schedule table
showing different types of 1.1. TYPE OF RECORD
records, inclusions or exceptions 1.1.1 Specific Explanatory notes, Disposal
and the various minimum 019.026.004 record inclusions or exclusions action
retention periods or disposal
actions
TRO Ref No.

this is the TRO reference number
or disposal class Entry Number Back to Table of Contents

Records
CHHS18/098
Section 1 – Patient/Client Registration and Identification
Records relating to the registration, admission, transfer and discharge of new or readmitted
patients/clients and the identification of patients/clients and the treatments or procedures
performed on them. Any registers, indexes and related records in electronic form must be
maintained in a readily accessible format for as long as they are required to be retained as
per the disposal action period.
Item Record Description Disposal Action

Number
TRO Ref No.
1.1. REGISTERS AND INDEXES
1.1.1 Admission and Listing of patients admitted or discharged Retain as Territory
019.026.004 Discharge each day. May also include time of Archives
Register admission, medical record number,
address, gender, date of birth, next of kin,
admitting diagnosis, discharge date and
length of stay.
1.1.2 Birth Register Recording details of each birth occurring in Retain as Territory
019.026.005 the service or facility Archives
Includes Birth and Labour Ward Registers,
confinement books or their equivalent.
1.1.3 Community Lists details of client Destroy 15 years
019.026.007 Health Register contacts/appointments including patient after last entry or
demographics, date seen etc. Also includes after youngest
Baby Health registers. child in the register
turns 18,
whichever is later
1.1.4 Death Register Recording details of each death occurring Retain as Territory
019.026.006 in the hospital or facility, including deaths Archives
on arrival (DOA’s).
1.1.5 Disease and Recording for each disease or condition Retain as Territory
019.026.002 Operation Index and operation or procedure code number, Archives
the details of each inpatient having that
diagnosis, or having undergone that
operation or procedure.
1.1.6 Duplicate Refers to records in hard copy or other Destroy 6 months
019.026.014 registration and format that duplicate details or after last action
index records information recorded in and accessible
from a centrally maintained registration
system.
1.1.7 Electro- A Register of Electro-Convulsive Therapy is Destroy 15 years
019.026.013 Convulsive required to be maintained under the after last entry
Therapy (ECT) Mental Health Act 2015.
Records
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Number
TRO Ref No.
Register
Sedation and
Seclusion
Register
Rapid
Tranquillisation
Journals
1.1.8 Emergency Lists details of patients attending the Retain as Territory
019.026.008 Department Emergency Department. Archives
Register
1.1.9 Patient Master The Patient Master Index (PMI) or Number Retain as Territory
019.026.001 Index (PMI) or Register is the key to locating an individual Archives
Number patient record in the medical records filing
Register system, providing a link between the name
of the patient and the facility’s medical
record number.
1.1.10 Physicians Index A recording for each medical practitioner Destroy 15 years
019.026.003 (If Held) with admitting rights and the details of after last entry
each patient admitted under the
practitioner during the period covered by
the index.
1.1.11 Register of Includes duplicates of records of Destroy 15 years
019.026.012 surgically accountable items used in operating after last action
implanted theatres e.g. instruments and swab counts
devices where they are used as the register.
1.1.12 Surgical Recording details of each surgical Retain as Territory
019.026.011 Procedures procedure carried out. Archives
Register Includes Operation Register or Theatre
Register. Can be in hard copy or electronic
format
1.1.13 Ward Register Records name of patient and date of Destroy 7 years
019.026.010 reception of individual patients into a ward after last action
1.2 LISTS AND SCHEDULES
1.2.1 Admission Lists, Where the Admission or Discharge Register Destroy 2 years
019.026.015 Transfer Lists does not exist, sentence in accordance after last entry
and Discharge with 1.1.1 019.026.004 Admission &
Lists Discharge Register.
1.2.2 Clinical lists Including outpatient lists, attendance Destroy 1 year
019.026.018 books etc. after last entry
1.2.3 Death lists Note: Where a Death Register does not Destroy 2 years
Records
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Number
TRO Ref No.
019.026.016 exist sentence in accordance with class after last entry
1.1.4 019.026.006 Death Register.
1.2.4 Operation/ e.g. Theatre Bookings Destroy 2 years
019.026.017 Theatre lists or after last entry
schedules
1.2.5 Waiting Lists Includes clerical audit reports Destroy 3 years
019.013.002 after last action
1.3 DIARIES AND APPOINTMENT BOOKS OR REGISTERS
1.3.1 Personal Recording details of appointments and Destroy 15 years
019.169.029 clinician/work patient contact not recorded elsewhere. after last entry
diaries or
Appointment
books/registers
1.3.2 Diaries/ Recording dates and times of client Destroy 6 months
019.169.030 Appointment meetings and appointments where clinical after last action
books. details of appointments or patient contact
is recorded elsewhere in the Patient
Administration System or clinical record.
1.4 WARD RECORDS
1.4.1 Ward or Group Records relating to the management, Destroy 7 years
019.169.027 session records treatment and care of patients over 18 after last action
- patients over years of age, on the ward, not incorporated
18 years into the main (unit) patient record eg
Group education sessions for pregnant
women, ward reports, report books and
related records.
1.4.2 Ward or Group Records relating to the management, Destroy 7 years
019.169.028 session records treatment and care of patients under 18 after patient
- patients under years of age, on the ward, not incorporated reaches age 18 or 7
18 years into the main (unit) patient record e.g. years after last
Group pregnancy education sessions, ward action, whichever is
reports, report books and related records. later
1.5 ELECTRONIC PATIENT ADMINISTRATION SYSTEMS (PAS)
1.5.1 Systems that When information systems are upgraded Sentence in
consist of and or replaced, records from the legacy accordance with
manage patient system should be migrated to the new specific record
personal (PMI), system if possible or must be accessible in class
admissions, some manner.
transfers,
separations
(ATS) and
disease index
Records
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Number
TRO Ref No.
details
1.6 DATA REPOSITORY (or Data Warehouse)
1.6.1 Extracted e.g. A Data Warehouse or Data Repository Destroy 3 years
019.088.009 electronic data of aggregated data for reporting, analysis after last action
from existing and service planning purposes where the
source systems source system retains original data.

Section 2 – Treatment and Care Records
Patient/client health records document an individual’s health evaluation, diagnosis,

treatment, care, progress and health outcome. Health records should be created and
maintained in accordance with the principles outlined in the ACT Health’s Clinical Records
Management Policy (accessible from the ACT Health Policy Register), the ACT Health Records
(Privacy and Access) Act 1997, and the Territory Records Act 2002, and in accordance with
any guidelines or directives that may be issued by the ACT Health from time to time.
Retention periods in this disposal authority reflect minimum clinical, legal or statutory
requirements. Before any destruction takes place, services must ensure that all legal
requirements for the records as evidence and local clinical needs are considered and that
the value of the records for research purposes has been assessed in consultation with the
relevant health professionals or Service Unit.

Number
TRO Ref No.
2.1 ADMITTED PATIENT CARE - Excludes Clinical Records described in Section 2.3 –
2.9
2.1.1 Acute Hospital Includes records of discharged or Destroy 15 years
019.169.002 Inpatient clinical deceased patients where the after last action
records – Patient patient is over 18 years of age.
over 18 years Excludes Records covered in
Sections 2.3 – 2.9:
 Obstetric/maternal health, see
019.169.010
 Genetic or inherited disorders,
see 019.169.001
 Sexual assault care, see
019.169.017, 019.169.018
 Child at risk, see 019.169.019
Records
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Number
TRO Ref No.
 Radiotherapy treatment see
019.169.024, 019.169.059
2.1.2 Acute Hospital Includes records of discharged or Destroy 15 years
019.169.003 Inpatient clinical deceased patients where the after the patient
records – Patient patient is less than 18 years of age. reaches the age of
under 18 years Excludes Records covered in 18 or 15 years after
Sections 2.3 – 2.9: last action,
 Obstetric/maternal health, see whichever is later
019.169.010, 019.169.011
 Genetic or inherited disorders,
see 019.169.001
 Sexual assault care, see
019.169.017, 019.169.018
 Child at risk, see 019.169.019
 Radiotherapy treatment see
019.169.024, 019.169.059
2.1.3 Non-Acute or Includes records of discharged or
Destroy 10 years
019.169.006 Extended Care deceased patients of non-acute
after last action
Facility care facilities over the age of 18.
Inpatient clinical
records Includes records of residents of
– Patient over 18 establishments registered under
years the Aged Care Act 1997.
2.1.4 Non-Acute or Includes records of discharged or Destroy 10 years
019.169.007 Extended Care deceased patients of non-acute after patient reaches
Facility care facilities less than 18 years of age 18 years or 10
Inpatient clinical age. years after last
records action, whichever is
– Patient under 18 later
years
2.2 NON- ADMITTED CARE - Excludes Clinical Records described in Section 2.3 – 2.9
2.2.1 Emergency Includes records of patients Destroy 7 years after
019.169.004 Department records presenting to Emergency last action
- Patient over 18 Departments and not admitted as
years in-patients, over 18 years of ages.
Includes patients who were dead
on arrival (DOA) and records
contained within the Emergency
Department Information System
(EDIS).
2.2.2 Emergency Includes records of patients Destroy 7 years after
019.169.005 Department records presenting to Emergency patient reaches age
Records
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Number
TRO Ref No.
- Patient under 18 Departments and not admitted as 18 years or 7 years
years in-patients, under 18 years of ages. after last action,
Includes patients who were dead whichever is later
on arrival (DOA) and records
contained within the Emergency
Department Information System
(EDIS).
2.2.3 Outpatient/Commun Records of non-admitted patients Destroy 7 years after
019.169.008 ity-based records over 18 years of age. Includes (but last action
- Patient over 18 not limited to) those attending:
years  hospital outpatient clinics or
receiving community based
care or non admitted patients
of day hospitals, day centres
and domiciliary care services.
Also includes
 Unregistered clients, clients
who are only “visitors”, clients
who are screened without
follow-up, potential clients or
clients who are referred
elsewhere.
 Community Health Records
 Immunisation Records
 Child/Baby health care
screening
 School Screening records
 Dental records and x-rays
 Telehealth consultation etc.
2.2.4 Outpatient/Commun Records of non-admitted patients Destroy 7 years after
019.169.009 ity-based records under 18 years of age. Includes patient reaches age
- Patient under 18 (but not limited to) those 18 years or 7 years
years attending: after last action,
 Hospital outpatient clinics or whichever is later
receiving community based
care or non-admitted patients
of day hospitals day centres
and domiciliary care services.
Also includes:
 Unregistered clients, clients
who are only “visitors”, clients
who are screened without
Records
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Number
TRO Ref No.
follow-up, potential clients or
clients who are referred
elsewhere.
 Community Health Records
 Immunisation Records
 Child/Baby health care
screening
 School Screening records
 Dental records and x-rays
 Telehealth consultation etc.
2.3 OBSTETRIC/MATERNAL HEALTH CARE
2.3.1 Obstetric/maternal Obstetric/maternal health care Retain as Territory
019.169.010 (mother’s) record - records documenting the birth Archives
episode.
2.3.2 Obstetric/maternal Record documenting a child/baby’s Retain as Territory
019.169.011 health care (baby’s) birth episode. Archives
records
2.3.3 Social work records Includes both maternal and child Retain as Territory
019.169.012 relating to instances (subject of Adoption) records. Archives
of arrangements for
adoption
2.4 PSYCHIATRIC AND MENTAL HEALTH CARE
2.4.1 Records of Includes admitted and non- Destroy 15 years
019.169.013 patients/clients admitted care where patient is after last action
receiving psychiatric over 18 years of age.
treatment and care
under the Mental
Health Act 2015 -
Patient over 18 years
2.4.2 Records of Includes admitted and non- Destroy 15 years
019.169.014 patients/clients admitted care where patient is after patient reaches
receiving psychiatric under 18 years of age. age 18 or 15 years
treatment and care after last action
under the Mental whichever is later
Health Act 2015 -
Patient under 18
years
2.5 GENETIC OR INHERITED DISORDERS
2.5.1 Genetic or inherited Records documenting the initial Retain as Territory
019.169.001 disease records diagnosis of a genetic or inherited Archives
disorder in patients/clients.
2.6 ASSISTED REPRODUCTIVE TECHNOLOGY (ART)
Records
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Number
TRO Ref No.
Technology (ART) procedures (including In Vitro Fertilisation, Gamete
intrafallopian transfer (GIFT) and artificial insemination
2.6.1 Records relating to Includes case records of each Destroy 75 years
019.169.015 ART where a child is individual person or family unit, after date of birth of
born or a pregnancy consent to ART procedures, use of the child or date of
achieved semen, ova or embryos and the insemination if the
withdrawal of consent for such date of birth is
procedures or processes. unknown
2.6.2 Records relating to Destroy 15 years
019.169.016 ART where a after last action
pregnancy was not
achieved, or the
procedure was
terminated.
2.7 SEXUAL ASSAULT RECORDS
2.7.1 Sexual assault Records relating to patients who Destroy 75 years
019.169.017 records were the victim of sexual assault after last action
- Patient over 18 who were over 18 years of age.
years
2.7.2 Sexual assault Records relating to patients who Destroy 75 years
019.169.018 records were the victim of sexual assault after date of birth of
- Patient under 18 who were less than 18 years of patient
years age.
2.8 CHILD AT RISK HEALTH RECORDS
2.8.1 Child at Risk Health Records relating to clients of the Destroy 75 years
019.169.019 Unit records Child at Risk Health Unit. after date of birth of
patient
2.9 RADIOTHERAPY TREATMENT
Specified retention periods are consistent with those recommended by the
RANZCR – The Royal Australian and New Zealand College of Radiologists.
2.9.1 Radiation Therapy Records documenting radiation Destroy 15 years:
019.169.059 records - Inpatient planning, treatment and dose  after death of
delivery in respect to admitted patient,
patients, who have undergone  or after the
radiotherapy treatment. Includes patient would
Dosimetry and calculation data. have reached
the age of 18
 or after last
action
whichever is the
later
2.9.2 Radiation Therapy Records documenting radiation Destroy 7 years:
Records
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Number
TRO Ref No.
019.169.060 records - non- planning, treatment and dose  after death of
admitted delivery in respect to non-admitted patient,
patients, who have undergone  or after the
radiotherapy treatment. Includes patients would
Dosimetry and calculation data. have reached
the age of 18
 or after last
action
whichever is the
later
2.9.3 Tech data and Maintain onward compatibility of Destroy 7 years:
019.169.024 Images. Localisation, storage media for any digitally  after death of
portal, EPID image stored records for the lifetime of patient,
proprietary digital the record class.  or after last
format. action
whichever is the
later
2.10 ELECTRONIC HEALTH RECORDS
Onward compatibility of digital record storage media must be maintained for the
lifetime of the original record class.
2.10.1 Extract summary Summary extracts created to Destroy 6 months
data facilitate the making of treatment after last action
decisions where the source records
still exist and are retrievable for
and at any particular point in time.
2.10.2 Original data where Maintain lifetime compatibility of Sentence in
the electronic record digitally stored records. accordance with
is the only record relevant record class
2.11 CORRESPONDENCE
If there is no record of the patient, note receipt of the correspondence in the
correspondence log book or register and return to sender.
See also 2.12 for records relating to the management and handling of complaints,
incidents, investigations or litigation involving the health service and its patients.
2.11.1 Correspondence Incoming and outgoing Destroy in
correspondence relating to the accordance with
treatment and care of individual specific record type
patients should be filed and
maintained as part of the main
health record and retained
accordingly.
2.11.2 Correspondence Log or Register of incoming and Destroy 7 years after
019.026.029 Register outgoing correspondence relating last action
Records
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Number
TRO Ref No.
to the treatment and care of
individual patients and/or clients.
2.11.3 Requests/ Received for services, where the Destroy 7 years after
019.169.020 referrals/ patient did not attend and no last action
correspondence service was provided.
- Patient over 18
years Includes Requests for Admission
forms for patients over 18 years of
age where the patient did not
attend.
2.11.4 Requests/ Received for services, where the Destroy 7 years after
019.169.021 referrals/ patient did not attend and no the patient reaches
correspondence - service was provided – the age of 18 or 7
Patient under 18 years after last
years Includes Requests for Admission action, whichever is
forms for patients under 18 years the later
of age where the patient did not
attend.
2.11.5 Requests or Includes requests from insurers or
Destroy 7 years after
019.169.057 applications for other third parties with written
last action
access to patient patient consent or valid
records by the authorisation to access the
patient, parent or patient’s clinical record.
third party.
2.12 LEGAL MATTERS AND INCIDENT MANAGEMENT
Includes correspondence between the health facility and solicitors or legal
defence organisations regarding a patient of the facility, complaint files, incident
reports and associated record of investigations into the incident or complaint.
For litigation not related to clinical services, use INFORMATION MANAGEMENT –
Enquiries
2.12.1 Records relating to Includes records relating to clinical Retain as Territory
019.068.001 clinical services services issues, claims or case Archives
issues, claims or case matters which are precedent-
matters involving setting in nature; or result in
legal action that are significant changes to the service
of major public or facility’s policy and/or
interest or procedures. (For subpoenas see
controversy. 2.12.5)
2.12.2 Records relating to Relating to clinical services case Destroy 15 years
019.068.002 clinical services matters involving legal action after last action
issues, claims or case issues that are not of major public
matters involving interest, controversy or precedent
Records
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Number
TRO Ref No.
legal action that are setting in nature. (For subpoenas
not of major public see 2.12.5)
interest
2.12.3 Records relating to Or resulted in major changes to Retain as Territory
019.084.001 complaints services, policies, procedures or Archives
investigated by the are precedent setting in nature.
Health Services
Commissioner,
which involved
significant public or
political interest
2.12.4 Records relating to Includes complaints and incidents Destroy 7 years after
019.084.002 complaints and investigated by the Health Services last action
incidents not Commissioner, not involving legal
involving legal action action or with no significant public
or political interest and were not
precedent setting in nature.
2.12.5 Subpoenas and Includes records of Destroy 7 years after
019.068.003 discovery orders correspondence concerning the last action
involving the health services’ or facility's receipt of and
service or facility’s compliance with a subpoena or
clinical services discovery order. It does not apply
to the records that are the subject
of the subpoena or discovery
order.
2.12.6 Subpoenas and Includes records of Destroy 3 years after
009.040.001 discovery orders correspondence concerning the last action
relating to other services’ or facility's receipt of and As per NI2001-92
litigation not directly compliance with a subpoena or INFORMATION
involving the health discovery order. It does not apply MANAGEMENT RDS –
service or facility to the records that are the subject Enquiries
of the subpoena or discovery
order.
2.12.7 Register of Patient Destroy 30 years
019.026.009 Injury Forms after last action
2.13 CLINICAL AUDITS
2.13.1 Records relating to Includes records of clinical quality Destroy 7 years after
019.013.001 the conduct of improvement activities e.g. records completion of audit
clinical audits for the relating to an audit of the outcome
purposes of evidence of pain management treatment.
based quality
management.
Records
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Number
TRO Ref No.
2.14 MEDICAL CERTIFICATES
Where possible a copy of any medical certificate issued is to filed and maintained
as part of the main (unit) patient/client records and retained accordingly
2.14.1 Medical certificates – Certificates issued to patients over Destroy 7 years after
019.169.022 Patient over 18 18 years of age detailing dates of last action
attendance and where appropriate
reason for attendance.
2.14.2 Medical certificates - Certificates issued to patients Destroy after patient
019.169.023 Patient under 18 under 18 years of age detailing reaches 25 years of
years dates of attendance and where age
appropriate reason for attendance.
2.15 STERILISATION OF MEDICAL/DENTAL EQUIPMENT
2.15.1 Sterilisation Print- A photocopy of the print-out Destroy 15 years
019.169.025 outs relating to should be made and kept with the after date of print-
sterilisation of original as fading may occur. For out
medical equipment dental equipment see 2.15.3
2.15.2 Log Books/ Destroy 15 years
019.169.026 Sterilisation Register after date of last
(if kept) used to keep entry
a record of
steriliser’s
performance
2.15.3 Sterilisation Print- Destroy 7 years after
019.169.058 outs relating to date of print-out
sterilisation of dental
equipment
2.16 SURGICAL PROCEDURES (accountable items)
2.16.1 Duplicates of records The original is required to be If additional to
of accountable items placed on the patient's file. Register of Surgically
used in operating Implanted devices,
theatres e.g. If used as a Register of Surgically destroy 1 year after
instruments and implanted devices sentence date of surgery (see
swab counts. according to 1.1.11 019.026.012 NAP destruction
(Retain as Territory Archives). page 30).

Section 3 – Patient Diagnosis – Imaging Services
Imaging procedures and tests performed for the purposes of patient/client diagnosis.
Includes diagnostic radiology, tomography, nuclear medicine, ultrasound, magnetic
resonance imaging and related diagnostic digital imaging procedures.
Records
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Number
TRO Ref No.
3.1. REQUESTS FOR DIAGNOSTIC IMAGING
3.1.1 Medical officer’s Diagnostic service copy of requests for Destroy 3 years
019.169.031 requests for a imaging procedures. after receipt of
diagnostic request
imaging
procedure
3.2 DIAGNOSTIC REPORTS
Records or reports documenting diagnostic findings based on an analysis,
evaluation or interpretation of recordings. The original or a copy of any
diagnostic report should be maintained as part of the individual patient record.
3.2.1 Medical Imaging Patient record copy. To be sentenced
Report in accordance
with the record
class they are
filed in.
3.2.2 Medical Imaging Originals or copies of diagnostic reports Destroy 3 years

019.169.032 Report - Service maintained by the diagnostic service. after date of
copy report
3.3 RECORDINGS - Recordings produced for or created as a result of diagnostic
processes
3.3.1 Visual/image/pict Includes diagnostic x-rays, videotapes, Destroy 7 years
019.169.033 orial recordings - films, photographs or equivalent image after last action
Patient over 18 recordings of patients over 18 years of age.
years
3.3.2 Visual/image/pict Includes diagnostic x-rays, videotapes, Destroy 7 years
019.169.034 orial recordings - films, photographs or equivalent image after patient
Patient under 18 recordings of patients under the age of 18. reaches age of
years 18 or after last
action,
whichever is
later
3.3.3 Graphical Recordings or tracings of a graphical nature Destroy 7 years
019.169.035 recordings - created via diagnostic measuring processes after last action
Patient over 18 e.g. Electroencephalograms (EEGs),
years Electrocardiograms (ECGs),
Cardiotocogram (CTGs).
3.3.4 Graphical Recordings or tracings of a graphical nature Destroy 7 years
019.169.036 recordings - created via diagnostic measuring processes after
Patient under 18 e.g. Electroencephalograms (EEGs), patient/client
years Electrocardiograms (ECGs), attains 18 years
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Number
TRO Ref No.
Cardiotocogram (CTGs). of age or last
action,
whichever is
later
3.4 REGISTERS – MEDICAL IMAGING
3.4.1 Registers or Destroy 7 years
019.026.019 control records after last action
maintained for
the identification
and location of
diagnostic
recordings and
reports

Section 4 – Patient Diagnosis – Pathology and Laboratory Services
Records of procedures and tests performed on body specimens for the purposes of
patient/client diagnosis.
The retention periods for these records reflect current minimum standards considered
acceptable for good laboratory practice in relation to the retention of laboratory records and
diagnostic material established by the National Pathology Accreditation Advisory Council
(NPAAC).

Number
TRO Ref No.
4.1 DIAGNOSTIC LABORATORY REQUESTS
4.1.1 Copy of requests for test or Held by the Diagnostic Destroy 3 years after
019.169.037 procedure Service. last action
4.2 DIAGNOSTIC RESULTS AND REPORTS
Records documenting diagnostic results, including copies or originals of
diagnostic reports, maintained by the pathology or laboratory service. This
includes records relating to the analysis, evaluation or interpretation of the
results of pathology or laboratory processes generated by an instrument or
operator and the records of test result validity.
An original or copy of any diagnostic report, including autopsy/post mortem
reports, should also be maintained as part of the main (unit) patient record.
4.2.1 Diagnostic anatomical Destroy 20 years

Records
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Number
TRO Ref No.
019.169.038 pathology, cytology and after last action
autopsy/ post mortem
results/reports/records,
registers, diagrams.
Diagnostic histopathology,
bone marrow
reports/records, including
copies of any
representative images
prepared.
4.2.2 Other diagnostic pathology Includes haematology, Destroy 7 years after
019.169.039 reports or records – Patient clinical chemistry, chemical last action
over 18 years pathology, microbiology and
immunology
reports/records.
4.2.3 Other diagnostic pathology Includes haematology, Destroy 7 years after
019.169.040 reports or records – Patient clinical chemistry, chemical patient reaches age
under 18 years pathology, microbiology and 18
immunology
reports/records.
4.2.4 Diagnostic genetics Includes karyotypes and Retain as Territory
019.169.041 reports/record digital images. Archives.
4.2.5 Diagnostic reports - Patient Reports documenting Sentence according
record copy diagnostic findings (including to relevant record
autopsy/post mortem). class
4.3 SPECIMENS AND SAMPLES
4.3.1 Bodily specimens, samples Includes slides, films, blocks, Refer to NPAAC
019.169.044 or materials examined in a cultures and related minimum standards
diagnostic pathology material. for the retention of
procedure laboratory
specimens and
material
4.3.2 Registers of bodily Includes registration details Destroy in
019.026.020 specimens collected or in laboratory information accordance with
received. systems. current NPAAC
standards
4.3.3 Extract summary data from Extract summary data used Destroy 6 months
019.026.021 the specimens register to undertake management after last action
activities (e.g. printouts of
reports to facilitate the
tracking or monitoring of
testing completion) and
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Number
TRO Ref No.
where no data/actions are
noted on the extract.
4.3.4 Extract summary data from Extract summary data from Destroy 3 years after
019.026.022 the specimens register the register used to last action
undertake management
activities (e.g. printouts of
reports to facilitate the
tracking or monitoring of
testing completion) and
where data or actions are
noted on that extract data.
4.3.5 Retained Human Tissue Records associated with the Destroy 20 years
019.169.045 Records management and consent in after tissue disposal
respect to retained human
tissue. Includes statutory
declarations, consent forms
and clinical information
about the deceased etc.
4.4 BLOOD BANK AND BLOOD PRODUCT COLLECTION SERVICES (includes autologous
and homologous)
These records should be created and maintained in accordance with the

requirements of the Human Tissue Act 1983 and Regulation 2000 and the
Therapeutic Goods Administration Australian Code of Good Manufacturing
Practice (GMP) for Therapeutic Goods: Blood and Blood Products.
The retention periods for these records also reflect current minimum standards
established by the GMP Code and the National Pathology Accreditation Advisory
Council (NPAAC), as required by the current Pathology Services Accreditation
(General) Regulations 2001.
4.4.1 Diagnostic results and Destroy 10 years
019.169.046 reports relating to blood after last action or
and blood products after donor reaches
the age of 30 years,
whichever is the
longer
4.4.2 Laboratory records of Records of administration Destroy 20 years
019.169.047 administration of blood should be included in the after last action or
and blood products Clinical Record. donor reaches age
30, whichever is the
longer.
4.4.3 Registers of blood products Containing details of fresh Destroy 20 years
Records
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Number
TRO Ref No.
019.026.023 and pooled blood products. after date of last
entry
4.5 SEMEN SUPPLY
4.5.1 Records relating to the Includes details of donor, Destroy 10 years
019.169.048 business of semen supply written consent, results of after last action or
tests and name of the after donor reaches
medical practitioner to the age of 30 years,
whom semen supplied. whichever is the
longer
4.6 PATHOLOGY LABORATORY QUALITY ASSURANCE RECORDS
4.6.1 Records relating to the This includes quality control Destroy 3 years after
019.085.001 certification, and quality assurance completion of review
implementation and audit records.
of Pathology Laboratory
processes and services.
4.7 EQUIPMENT MAINTENANCE
4.7.1 Records relating to the Refer to TRO Disposal Destroy 3 years after
12- maintenance and servicing Schedule NI2012-186 - the equipment has
186/003.069. of diagnostic equipment. Equipment and Stores been replaced or
001 Records - 12- disposed of or 25
186/003.069.001. years for equipment
used on paediatric
patients
4.8 PROCEDURES AND METHODS
4.8.1 Pathology Laboratory Destroy 15 years
019.082.001 methodologies and after
standard procedures. methods/procedures
superseded

Section 5 – Pharmaceutical Supply and Administration
Management of the supply, administration, dispensing and use of pharmaceuticals,

encompassing drugs. Medication orders written by medical staff and records of
administration should be filed and maintained as part of the main patient record.
Relevant legislation regarding prescriptions and medication administration records includes:

 ACT legislation Medicines, Poisons and Therapeutic Goods Act 2008
 Schedule of Pharmaceutical Benefits for Approved Pharmacists and Medical
Practitioners
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 Federal taxation legislation where Commonwealth reimbursement for S100

medication was received.

Number
TRO Ref No.
5.1 PHARMACEUTICAL SUPPLY
5.1.1 Cytotoxic Drug Includes prescriptions and Destroy 2 years after
019.169.049 prescriptions records of supply. dispensing.
5.1.2 Drugs of Includes prescriptions and Destroy 2 years after
019.169.050 Dependence records of supply. dispensing.
prescriptions
5.1.3 Inpatient Pharmacy copy - Originals are Scanned Pharmacy copies
019.169.051 prescriptions retained in the clinical record. destroyed 2 years after
date of dispensing
5.1.4 Intravenous Includes prescriptions and Pharmacy copies can be
019.169.052 additives manufacturing records. destroyed 2 years after
dispensing.
Original Intravenous prescriptions
are retained in the clinical record.
5.1.5 Outpatient Includes prescriptions and Destroy 2 years after
5.1.6 S100 Includes prescriptions and Destroy 2 years after
5.2 PHARMACEUTICAL ADMINISTRATION
5.2.1 Stock and Includes requisitions/ orders for Destroy 2 years after last
019.061.001 inventory control pharmaceutical products or action
records substances and receipts/records
of delivery.
5.2.2 Drugs Registers Includes Drugs of Dependence, Destroy 2 years after last
019.026.025 S4D Drug Registers & Prohibited action
Substances registers held in the
Pharmacy Department, Ward or
other department.

Section 6 – Notifications – Data Collection
Notification and reporting to prescribed bodies re patient medical conditions or instances, in

accordance with statutory/other requirements e.g. Public Health Act 1997.

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Number
TRO Ref No.
6.1. BIRTHS AND DEATHS Original notification forms are retained by Births, Deaths
and Marriages.
6.1.1 Copies of birth Copies held in the patient record. Sentence according
registration forms to specific record
class
6.1.2 Copies of death Retained separately from the main Destroy 1 year after
019.088.007 certificates patient record date of notification
6.2.0 HEALTH REPORTING
6.2.1 Notifiable Disease Copies of reports/notification forms Destroy 15 years
019.088.003 notification forms held by the notifier (e.g. public after last action
– Patient over 18 health facility hospitals, community
years health services).
6.2.2 Notifiable Disease Copies of reports/notification forms Destroy after patient
019.088.004 notification forms held by the notifier (e.g. public reaches age 25
– Patient under 18 hospitals, community health years
years services).
6.2.3 Notifiable Disease Records relating to the initial report Destroy 7 years after
019.088.005 reports of an incidence of a notifiable receipt of
disease maintained by Public Health notification
Units.
6.2.4 Notifiable Disease Duplicate records of notifications Destroy 6 months
019.088.008 reports - duplicates received by Public Health Units after receipt of
subsequent to the initial notification. notification
1.4.2 Data Collection Original data collection forms e.g. Destroy 6 months
019.088.001 Records – Originals midwife data collection, brain injury after last action
submitted by hospitals, held by
Public Health Agency.
1.4.3 Data Collection Copies of data collection forms Destroy 3 years after
019.088.002 Records – Copies retained after submission of submission date
originals, held by hospitals or
submitting health facilities.
6.2.5 Cancer Notification Hospital or notifying facility copy - Destroy 2 years after
019.088.006 forms Where possible a copy of Cancer date of submission
notification form is to be filed as part
of the main patient record.
6.2.6 PAP Test Register Register held and maintained by Destroy 15 years
019.026.024 Central Cancer Registry in after last action
accordance with Public Health Act
1997.

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Section 7 – Patient Finance and Property Management
Management of patient/client finances and property during their admission to a facility or

service.

Number
TRO Ref No.
7.1.0 PATIENT PROPERTY Records relating to the management of patient property
7.1.1 Patient property and Destroy 7 years from
019.026.027 wearing apparel Books last action
7.1.2 Patient money and Destroy 7 years from
019.026.026 valuables Register last action
7.1.3 Patient/Client Destroy 7 years from

019.169.042 Authorities to make date of authority
payment or transfer
property
7.2 PATIENT/CLIENT ACCOUNTS AND FINANCES RECORDS RELATING to the
management of patient finances including accounts, benefits and claims.
7.2.1 Assigned benefits Destroy 1 year after
019.169.043 claim books (if last entry completed
maintained)
7.2.2 Hospital private Includes records documenting Destroy 7 years from
019.169.042 patient claim and the management of patient last action
assignment forms finances e.g. accounts, benefits,
claims, HC21 forms & Patient
Election Forms.
7.2.3 Register of patients Destroy 7 years from
019.026.028 admission and account last action
forms (if maintained)
7.3 PROGRAM OF APPLIANCES FOR DISABLED PEOPLE - Regard should be had to the
life span of equipment when determining the destruction of records
7.3.1 Applications for aids, e.g. ACT Equipment Loan Service, Destroy 7 years from
019.169.056 appliances and ACT Equipment Scheme (ACTES) last action or after
disability services and/or the Home and Community patient reaches age
Care (HACC) Equipment Scheme. 18, whichever is later
7.3.2 Records relating to the E.g. ACT Equipment Scheme Destroy 7 years from
019.169.055 provision of aids, (ACTES) and the Home and last action or after
appliances and Community Care (HACC) patient reaches age
disability services Equipment Scheme services. 18, whichever is later

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Section 8 – Research Management
Records relating to conduct of clinical and non-clinical research. This includes records or
documentation relating to the collection of data, data analysis, preliminary findings, surveys
and results.
Item Record Description Disposal

Number Action
TRO Ref No.
8.1 RESEARCH PROJECTS, TRIALS OR STUDIES
Retention periods based on recommendations in National Health and Medical
Research Council (NHMRC) Australian Code for the responsible conduct of
research – 2007. For records relating to population health care management
and control programs and strategies research, use POPULATION HEALTH CARE
MANAGEMENT AND CONTROL – Research. NI2009- 209]
8.1.1 Records relating to the Includes records or documentation Retain as
019.091.001 conduct of clinical and relating to the recruitment and Territory
non-clinical research consent of research participants, the Archives
considered significant, collection and analysis of data,
unique, precedent preliminary findings, surveys and
setting or results in results.
major breakthroughs in
treatments.
8.1.2 Records and requests Includes records or documentation Destroy 15
019.091.002 relating to the conduct relating to the recruitment and years after last
of clinical research not consent of research participants, the action or date
considered significant to collection & analysis of data, of publication
the Territory. preliminary findings, surveys & results. whichever is
later
8.1.3 Records relating to the Includes records or documentation Destroy 7
019.091.003 conduct of non-clinical relating to the recruitment and years after
research not considered consent of research participants, the date of
to be significant to the collection and analysis of data, publication or
Territory. preliminary findings, surveys and termination of
results. the study
8.1.6 Records relating to Destroy 3
019.091.004 clinical and non-clinical years after last
research where the action
research does not
proceed.
8.1.7 Human Research Ethics Records relating to clinical trial Destroy 7
019.020.001 Committee Records projects submitted to the Committee years after
for approval. For records date of
documenting Human Research Ethics publication or
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Item Record Description Disposal

Number Action
TRO Ref No.
Committee’s and other health related termination of
committee’s meetings, refer to Patient the study
Services Administration RDS NI2009-
210 –Committees

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Section 9 – Digitised Records (duplication/scanning)
Duplication of records by means of imaging technologies for storage, access, reference or

related records management purposes.

Number
TRO Ref
No.
9.1 RECORDS THAT HAVE BEEN DIGITISED
Refers to patient/client records which have been subject to processes resulting in
the creation of authentic, complete and accessible image copies in digital, electronic
or microfilm format. E.g. scanning.
Note: Originals of records that have been imaged or duplicated in a way that does
not comply with the requirements of the Evidence Act 2011 or the Electronic
Transactions Act 2001 will need to be retained and disposed of in accordance with
the requirements for the type of records they comprise.
Where records have been converted to digital storage, onward compatibility of

storage media must be maintained for the lifetime of the record class.
9.1.1 Source records - Retention periods must allow Sentence according to
original versions of adequate time for data approved Digitisation
records that have verification and audit/quality Plan
been digitised assurance processes.
9.1.2 Master copies of Maintain onward compatibility of Sentence according to the

imaged records storage media for digitally stored specific record class
records for the lifetime of the
original record class.
9.1.3 Working, reference Retain until no longer required Destroy 6 months after
or superseded copies for administrative purposes or last action
of imaged records until reference ceases, then
destroy.
9.1.4 Affidavits and Retain until the master copy of Destroy when no longer
documentation the records to which they relate required
relating to records is destroyed or superseded.
authenticity

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Section 10 – Normal Administrative Practice (NAP) Records
According to Territory Records Advice No 2, Normal Administrative Practice (NAP) allows for
the destruction of transitory, ephemeral or duplicate material that has limited or short term
value, as part of normal agency practices and procedures.

Number
TRO Ref
No.
10.1 TEMPORARY OR INTERIM RECORDS
10.1.1 Draft documents Where the contents have been Destroy when no
reproduced in a final document or longer required
subsequent draft.
10.1.2 Duplicate documents Copies of clinical record documents that Destroy when no
have not been annotated in any way, longer required
where the original is retained within the
clinical record.
10.1.3 Handover notes Clinical worksheets and notes made to Destroy at end of
facilitate clinical handover during corresponding shift
change of shifts which
summarise/duplicate information
documented within the clinical record.
10.1.4 Working notes Includes calculations or diagrams used Destroy when no
to assist in the creation of final records longer required
or rough notes later transcribed into the
clinical record.
10.1.5 Visual recordings of Destroy when no
diagnostic longer required
procedures for
education/training
purposes
Section 11 – Summary of the Destruction Process
1. Contact the Clinical Record Service (email to TCHMedicalRecords@act.gov.au or phone

6244 2124), to verify applicable retention periods and seek approval to destroy records.
Describe the date range of records, format and volume of records intended for
sentencing/destruction;
2. Carry out the appraisal and sentencing of records, i.e. determine from the Records
Disposal Schedules which records can be disposed of, under what class and at what time.

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3. Update and maintain your Control Records to reflect the disposal decision and date e.g.
Track relevant volumes to “DESTROYED” within ACTPAS Document Tracking.
4. Ensure that no restrictions to destruction apply including:
a. Current or known pending litigation (confirm with the Insurance and Legal Liaison
Unit)
b. Records subject to a TRO Records Disposal Freeze (check the TRO website
http://www/territoryrecords.act.gov.au/recordsadvice)
5. Assist the Clinical Record Service to complete a formal Notification to TRO of Records
Destroyed form (Appendix A) with a listing of all sentenced records (URN only - patient
names not required)
6. Ensure the records are securely destroyed.

Implementation
The Records Disposal Schedule will supersede the previous version once published on the
ACT Health policy and Plans Register and communicated to staff via the Policy notification
emails.

Related Policies, Procedures, Guidelines and Legislation
A range of policies relevant to the management of records must be applied alongside this
policy, including:
 Clinical Record Management Policy
 Data Quality Framework, DGC14-006
 ACT Public Service Code of Conduct
 ACT Public Service Code of Ethics
 ACT Health Clinical Record Digitisation Plan
Procedures
 Clinical Record Management Operational Procedures
Legislation
 Electronic Transactions Act 2001
 Epidemiological Studies (Confidentiality) Act 1992
 Evidence Act 2011
 Financial Management Act 1996
 Freedom of Information (FOI) Act 1989
 Health Act 1993
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 Health Records (Privacy and Access) Act 1997

 Human Rights Commission Act 2005
 Medicines Poisons and Therapeutic Goods Act 2008
 Mental Health Act 2015.
 Privacy Act 1988 (Cwlth)
 Public Health Act 1997
 Public Sector Management Act 1994
 Territory Records Act 2002

Definition of Terms
Administrative Record Classes - Are those TRO record classes based on the Territory Whole
of Government Thesaurus which primarily reflects the functions and activities within the
Business Classification Scheme for administrative records. These include “Audit”,
“Committee”, “Control”, “Inventory”, “Procedures”, “Public Reaction” etc.
Agency - The Executive, an ACT Court, the Legislative Assembly Secretariat, an administrative
unit, a Board of Inquiry, a Judicial or Royal Commission, any other prescribed authority, or an
entity declared under the regulations of the Territory Records Act 2002 to be an agency.
Control Records - Are those records used to assist in recording/tracking the location and
status of records, e.g. Registers, tracer cards, computerised record tracking systems etc.
Disposal Freeze - A Records Disposal Freeze is a government directive to suspend the

sentencing and destruction of Territory Records. The aim of a records disposal freeze is to
minimise the risk of losing crucial evidence at, or around the time when an issue has been
identified. To determine if a records disposal freezes is current or applicable to clinical
records refer to the Territory Records Office.
Entry No. - See TRO Ref No.
Health Record - defined in the Health Records (Privacy and Access) Act 1997 as:
Any record, or any part of a record:
a. held by a health service provider and containing personal information; or
b. containing personal health information
Health Service - (a) any activity that is intended or claimed (expressly or by implication), by
the person providing it, to assess, record, improve or maintain the physical, mental or
emotional health of a consumer or to diagnose or treat an illness or disability of a consumer;
or (b) a disability, palliative care or aged care service that involves the making or keeping of
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personal health information; but does not include any service declared by regulation to be
an exempt service.
Health Service Provider - An entity that provides a health service in the ACT.
Record - defined in the Health Records (Privacy and Access) Act 1997 as:
Means a record in documentary or electronic form that consists of or includes personal
health information in relation to a consumer (other than research material that does not
disclose the identity of the consumer), and includes—
a. a photograph or other pictorial or digital representation of any part of the consumer;
and
b. test results, medical imaging materials and reports, and clinical notes, relating to the
consumer; and
c. any part of a record; and
d. a copy of a record or any part of a record.
Records Disposal Schedule - A document approved by the Director of Territory Records,

which sets out the types of records an agency must make and how long they must be kept.
Sentencing - The process of applying appraisal decisions to individual records by determining

the part of a Records Disposal Schedule that applies to the record and assigning a retention
period consistent with that part.
Territory Archives - Records retained indefinitely to preserve them for the benefit of present
and future generations.
TRO Ref No. - The TRO Ref No. refers to the disposal class Entry Number allocated by the
Territory Records Office (TRO) in the approved TRO Records Disposal Schedule i.e. Territory
Records (Records Disposal Schedule – Health Treatment and Care Records) Approval 2017 (No 1) -
Notifiable instrument NI2017—629. This number must be quoted when seeking approval for
destruction.

Search Terms
Records, disposal, Clinical Records, disposal schedule, sentencing, medical records,

destruction, patient records.

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Appendices
Appendix A – TRO Records Disposal Concurrence Form

Appendix B – Index
Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services
specifically for its own use. Use of this document and any reliance on the information contained therein by any
third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
Policy Team ONLY to complete the following:

Date Amended Section Amended Divisional Approval Final Approval
14/03/2018 Complete Review Lisa Gilmore, A/g CSS CHHS Policy Committee
This document supersedes the following:

Document Number Document Name
DGD14-005 Records Disposal Schedule for ACT Health Clinical Records

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Appendix A – TRO Records Disposal Concurrence Form

This form to be completed by the agency Records Manager and forwarded to the Territory Records Office.
Under the Territory Records Act 2002, agencies are required to dispose of records in accordance with approved
disposal schedules. This form notifies the TRO of this destruction.
AGREEMENT TO DESTROY TERRITORY RECORDS
The records on the attached list have met their minimum retention period and are ready for final
disposal. ACT government organisations must ensure that records have been correctly identified for
destruction and are no longer required for any business purpose, including for reasonably foreseeable
legal purposes, including Freedom of Information requests, before the records are destroyed. The
Territory Records Office must also be consulted before records are destroyed.
If your business unit has no ongoing business or legal need to retain these records, please sign all
relevant areas of this form to indicate that you approve of their disposal.
Approval from: …………………………………………………………………………………………………………..
Business Unit/Area: …………………………………………………………………………………………………………..
Legal Officer: …………………………………………………………………………………………………………..
FOI officer: …………………………………………………………………………………………………………..
Date: …………………………………………………………………………………………………………..
This section is to be completed by the organisation’s head of the records management unit or the
records manager
Have the records been sentenced correctly? Yes No

Have the records satisfied the minimum retention requirements? Yes No
Were the records created prior to 1931? Yes No
Are the records subject to any current disposal freeze? Yes No
Are you satisfied that the records are not required for any
reasonable foreseeable legal proceedings including FOI requests? Yes No
Name: Signature:
Position: Date:
This section is to be completed by the Territory Records Office
Record Disposal authorised EXCEPT where noted on the attached list:
Name: Signature:
Position: Date:

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Record destruction details To be

attached with the destruction request
File number or Class No. File title
control symbol (TRO Ref No)

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Appendix B – Index
Accountable items used in operating Dental records and x-rays.......................10
theatres...............................................17 Diagnostic genetics reports.....................20
ACTES - ACT Equipment Scheme............26 Diagnostic imaging records.....................17
Acute Hospital Inpatient clinical records. .8 Diagnostic pathology reports..................20
Admission and Discharge Register............4 Diagnostic radiology................................17
Admission Lists..........................................6 Diagnostic x-rays.....................................18
Admitted patient care records..................7 Diaries/appointment books......................6
Adoption..................................................11 Discharge Lists...........................................6
Affidavits relating to record authenticity 28 Discovery orders......................................15
Applications for aids, appliances and Disease and Operation Index....................4
disability services.................................26 Dispensing of pharmaceuticals...............22
Appointment books/registers...................6 DOA - Dead on arrival records...................9
ART - Assisted Reproductive Technology Dosimetry and calculation data..............12
records.................................................11 Draft documents......................................29
artificial insemination.............................11 Drug Registers.........................................23
Assisted Reproductive Technology Drugs of Dependence prescriptions........23
records................................................11 Duplicate documents..............................29
Autopsy reports/records........................19 Duplicate registration and index records..4
Birth Register.............................................4 Electro-Convulsive Therapy (ECT) Register
Birth registration records........................24 ...............................................................5
Blood and blood products.......................21 Electroencephalograms (EEGs)...............18
Bone marrow reports..............................19 Electronic Patient Information System.....7
Cancer Notification forms.......................25 Emergency Department records...............9
Cardiotocogram (CTGs)...........................18 Emergency Department Register..............5
Child at Risk Health Unit records.............12 Equipment Scheme.................................26
Child/Baby health care screening...........10 Ethics Committees...................................27
Clerical audit reports.................................6 Extract Health Records............................13
Clinical audit records...............................16 Extracted electronic data..........................7
Clinical lists................................................6 Gamete intrafallopian transfer..............11
Community Health Records................9, 10 Genetic or inherited disease records......11
Community-based care records................9 Genetics reports......................................20
Complaints...............................................15 Haematology reports..............................19
Correspondence......................................13 Handover notes.......................................29
Correspondence Register........................14 HC21 forms..............................................26
Cytotoxic Drug prescriptions...................23 Histopathology records/reports..............19
Data Collection Records..........................24 Home and Community Care (HACC)
Data Repository.........................................7 records.................................................26
Data Warehouse.......................................7 Hospital private patient claim forms.......26
Death certificates....................................24 Human Research Ethics Committee
Death lists..................................................6 Records................................................27
Death Register...........................................4 Human Research Ethics Committees.......27
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Imaging procedures.................................17 Patient money and valuables Register....25

Immunisation Records.............................10 Patient property and wearing apparel
Immunology reports................................19 Books...................................................25
In Vitro Fertilisation................................11 Patient/Client Authorities to make
Incidents..................................................15 payment or transfer property.............25
Inpatient clinical records...........................8 Personal clinician/work diaries................6
Inpatient prescriptions............................23 Pharmaceutical supply records...............22
Intravenous additives..............................23 Physicians Index (If Held)..........................5
Karyotype records...................................20 PMI............................................................7
Legal records...........................................14 Post mortem reports..............................19
Log Books - Sterilisation..........................16 Prescriptions............................................23
Maintenance of diagnostic equipment...22 Psychiatric and Mental Health records...11
Medical certificates.................................16 Radiation Therapy records......................12
Medical Imaging......................................17 Rapid Tranquillisation Journal...................5
Medical Imaging Registers......................18 Recordings or tracings of a graphical
Medication Management........................22 nature..................................................18
Medicolegal Records...............................15 Records relating to the maintenance of
Mental Health treatment records...........11 diagnostic equipment..........................22
Microbiology...........................................19 Records that have been
Midwife data collection...........................24 imaged/duplicated.............................28
Non admitted patient records...................9 Referrals..................................................14
Non-Acute or Extended Care Facility........8 Register of Patient Injury Forms..............16
Non-clinical research...............................26 Register of surgically implanted devices...5
Normal Administrative Practice..............29 Requests for Admission...........................14
Notifiable Disease notification forms......24 Requests from insurers...........................14
Notification s and Data Collection records Requests from third parties....................14
.............................................................24 Research..................................................27
Obstetric/maternal health care records. 11 Research Records....................................26
Obstetric/maternal social work records. 11 Retained Human Tissue Records.............21
Operation/Theatre lists.............................6 S100 prescriptions...................................23
Originals of records that have been School Screening records........................10
imaged.................................................28 Sedation and Seclusion Register...............5
Outpatient prescriptions.........................23 Semen supply records.............................22
Outpatient records....................................9 Sexual assault records.............................12
Outpatient/Community-based records.....9 Source records.........................................28
PAP Test Register.....................................25 Sterilisation Print-outs.............................16
PAS - Patient Administration Systems.......7 Sterilisation Register...............................16
Pathology and Laboratory records..........19 Stock and inventory control records of
Pathology Specimens and Samples.........20 phamaceuticals....................................23
Patient Election Forms............................26 Subpoenas...............................................15
Patient Injury Forms................................16 Surgical Procedures Register.....................5
Patient Master Index or Number Register 5 Telehealth consultation...........................10
Records
CHHS18/098
Theatre bookings.......................................6 Waiting Lists..............................................6

Theatre Register........................................5 Ward or Group session records.................6
Tracings of a graphical nature.................18 Ward Register............................................5
Transfer Lists............................................6 Warehouse - Data.....................................7
Unregistered clients................................10 Working notes.........................................29
Visual recordings of diagnostic procedures X-rays.......................................................18
for education/training purposes.........29

Records

Records Disposal Schedule For ACT Health Clinical Records

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Records Disposal Schedule For ACT Health Clinical Records

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CHHS18/098

Canberra Hospital and Health Services

Doc Number Version Issued Review Date Area Responsible Page

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Section Heading: 1. Functional Record Category

TRO Ref No.

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Section 1 – Patient/Client Registration and Identification

Item Record Description Disposal Action

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Patient/client health records document an individual’s health evaluation, diagnosis,

Item Record Description Disposal Action

Item Record Description Disposal Action

Item Record Description Disposal Action

Item Record Description Disposal Action

Item Record Description Disposal Action

Item Record Description Disposal Action

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3.2.2 Medical Imaging Originals or copies of diagnostic reports Destroy 3 years

Item Record Description Disposal Action

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These records should be created and maintained in accordance with the

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Management of the supply, administration, dispensing and use of pharmaceuticals,

Relevant legislation regarding prescriptions and medication administration records includes:

 Federal taxation legislation where Commonwealth reimbursement for S100

Item Record Description Disposal Action

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Notification and reporting to prescribed bodies re patient medical conditions or instances, in

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Section 7 – Patient Finance and Property Management

Management of patient/client finances and property during their admission to a facility or

Item Record Description Disposal Action

7.1.3 Patient/Client Destroy 7 years from

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Section 8 – Research Management

Item Record Description Disposal

Item Record Description Disposal

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