Australian Capital Territory
Territory Records (Records Disposal Schedule – Health Treatment and Care Records) Approval 2013 (No 1)
Notifiable instrument NI2013-589
made under the
Territory Records Act 2002, s 19 (Approval of schedules for the disposal of records)

1.	Name of Instrument
This instrument is the Territory Records (Records Disposal Schedule – Health Treatment and Care Records) Approval 2013 (No 1)
2.	Approval
I approve the Records Disposal Schedule – Health Treatment and Care Records.
3.	Commencement
This instrument commences on the day after notification.

Danielle Wickman
Director of Territory Records
19 December 2013

Records Disposal Schedule
Health Treatment and Care Records

Table of Contents
INTRODUCTION	4
PURPOSE	4
SCOPE	4
AUTHORITY	4
STRUCTURE AND RELATIONSHIP TO THE TERRITORY WHOLE OF GOVERNMENT THESAURUS	4
Whole of Government Thesaurus	5
GUIDELINES FOR USE	5
Coverage of authority	5
Layout of the schedule	6
FORMAT OF RECORD	7
Electronic records	7
DESTRUCTION OF RECORDS	7
UPDATING THE RECORDS DISPOSAL SCHEDULE	7
ASSISTANCE IN USING THE RECORDS DISPOSAL SCHEDULE	7
RELATED LEGISLATION	8
DEFINITIONS	9
Agency	9
Appraisal	9
Business Classification Scheme	9
Converted Record	9
Health Record	9
Health Service	9
Health Service Provider	9
Last Action	10
Principal Officer	10
Record	10
Recordkeeping Systems	10
Records of an Agency	10
Records Disposal Schedule	10
Records Management Program	10
Scope Note	11
Sentencing	11
Source Record	11
Territory Archives	11
BUSINESS CLASSIFICATION SCHEME	12
HEALTH TREATMENT AND CARE	13
RECORDS DISPOSAL SCHEDULE	15
HEALTH TREATMENT AND CARE	16
Audit	16
Committees	16
Control	17
Control (Continued)	18
Control (Continued)	19
Inventory	20
Litigation	20
Litigation (continued)	21
Procedures	21
Public Reaction	22
Quality Assurance	22
Reporting	23
Reporting (Continued)	24
Research	25
Service Provision	26
Service Provision (Continued)	27
Service Provision (Continued)	28
Service Provision (Continued)	29
Service Provision (Continued)	30
Service Provision (Continued)	31
Service Provision (Continued)	32
Service Provision (Continued)	33
Service Provision (Continued)	34
Service Provision (Continued)	35
RETAIN AS TERRITORY ARCHIVES	36
HEALTH TREATMENT AND CARE	37
Control	37
Litigation	38
Public Reaction	38
Research	38
Service Provision	39
INDEX	40

INTRODUCTION
The Records Disposal Schedule – Health Treatment and Care Records is the official authority for the disposal of these ACT Government Records.
It is one of a series of Records Disposal Schedules authorised by the Director of Territory Records in accordance with the provisions of the Territory Records Act 2002. It is used in conjunction with other Territory Records Disposal Schedules.
PURPOSE
The purpose of this Records Disposal Schedule is to provide for the authorised disposal of records created or maintained by ACT Government Agencies.
SCOPE
This Records Disposal Schedule applies to records created or maintained by ACT Government Agencies. It applies to records in any format, including electronic records.
AUTHORITY
The Director of Territory Records, in consultation with stakeholders and the Territory Records Advisory Council, has approved this Records Disposal Schedule for use. The schedule does not take effect until it has been incorporated into an agency's Records Management Program that has been signed off by the Principal Officer of the agency.
Even so, officers using this Records Disposal Schedule should apply it with caution. They should be aware that the authorisations for disposal are given in terms of the Territory Records Act 2002 only. Officers must not dispose of records in contravention of this Records Disposal Schedule or other requirements such as a records disposal freeze.  Current records disposal freezes can be found at the Territory Records Office Internet site http://www.territoryrecords.act.gov.au/recordsadvice.
This Records Disposal Schedule will remain in force until a new schedule supersedes it or the Director of Territory Records withdraws it from use.
STRUCTURE AND RELATIONSHIP TO THE TERRITORY WHOLE OF GOVERNMENT THESAURUS
A Records Disposal Schedule generally specifies retention periods. That is, how long records are to be retained by the agency before being destroyed or retained as Territory Archives.
Retention periods set down in this schedule are minimum periods only and an agency may keep records for a longer period if considered necessary for business requirements. Reasons for longer retention could include legal requirements, administrative need or agency directives. An agency must not dispose of any records where it is 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.
The Records Disposal Schedule – Health Treatment and Care Records has a hierarchical structure that reflects its arrangements according to functions and activities, rather than by subject, and this also reflects a close relationship to the Territory Whole of Government Thesaurus originally based on the Territory Version of Keyword AAA. The Records Disposal Schedule is designed to be applicable to all ACT Government records regardless of titling conventions used, so that records, which have not been titled using the terminology represented by this Records Disposal Schedule, may still be sentenced with relative ease.
Whole of Government Thesaurus
The Whole of Government Thesaurus is a controlled vocabulary of terms designed for use in the classifying, titling and indexing of records on creation.
The Whole of Government Thesaurus has been developed on the basis of the Territory Version of Keyword AAA (TVKAAA 2010), a thesaurus which incorporated 16 common functions. All other functions within the Whole of Government Thesaurus are considered functions performed by the ACT Government and have been included following consultation with agencies and after consideration by the Territory Records Office (TRO) via a formal approval process.
The Whole of Government Thesaurus is mandated by the TRO for use by all ACT Government agencies as part of their classifying and titling of paper and electronic records.  See also Records Advice No.28 Functional directories on shared drives.
The disposal actions listed in this Records Disposal Schedule were determined through the process of appraisal in accordance with Territory Records Office Standard for Records Management No.2 - Appraisal. Appraisal is based upon the same type of analysis of business activity employed in the classification scheme used in the original Territory Version of Keyword AAA. Essentially, appraisal involves attaching record retention periods and disposal decisions (and even records creation requirements and rules) to the same classification scheme.
GUIDELINES FOR USE
Coverage of authority
The Records Disposal Schedule - Health Treatment and Care Records:
•	covers all records related to the function;
•	is intended to be used in conjunction with other Territory Records Disposal Schedules;
•	specifies the minimum period records should be kept (retention periods) 
•	specifies whether, upon the expiry of the retention periods, the records may be destroyed or are required as Territory Archives; and
•	is applicable to records created and maintained in any format, including electronic or formats such as microfiche.
Layout of the schedule
This Records Disposal Schedule begins with an introduction incorporating definitions and the business classification scheme. Then each of the functions and activity disposal sets or 'disposal classes' relating to the functions are described. These are followed by a composite list of classes designated 'Retain as Territory Archives'. The functions and activity disposal sets show the following details:
Function
This is the broad level business function and is displayed in bold capital letters at the top of each page. It is the highest level in the business classification scheme. It is followed by the scope note, which provides definitions of the function and a collective view of the business activities that make that function unique.
Activity
Activities are the processes or operations that make up the business function. They are set in bold and italics below the function statement. This is the second level of the business classification scheme. The scope of the activity encompasses all of the transactions that take place in relation to the activity. Activities can relate to many functions with the scope notes covering all of these relationships (e.g., the activity 'Policy' is linked to all of the functions). However, each function and activity set represents a unique unit.
Entry No.
This is the disposal class number allocated based on the function and activity set and the class number of the record. The barcode is the same as the Entry No. and may be used in an automated recordkeeping system.
Description of Records
This is the description of the records documenting the business function, activity and transactions. The descriptions can relate to one record such as a register or a group of records documenting a particular set of transactions.
Disposal Action
This is the minimum period a record must be kept for and is the trigger event from which the disposal date can be calculated.

FORMAT OF RECORD
This Records Disposal Schedule is applicable to any record that performs the function prescribed, irrespective of format. Records may include:
•	cards;
•	registers;
•	files;
•	microfilm;
•	COM (computer output microfiche);
•	electronic records, including various electronic media, and
•	any other formats.

Electronic records
Refers to records created, communicated and maintained by means of electronic equipment. Information could be maintained/stored in a number of ways - on the database (the main database, or a special archives database); on magnetic media; on optical disks; or on separate hardcopy (paper, COM).
Electronic records must be readily accessible for the length of the specified retention period. Routine treatment (such as wiping, updating, alterations or re-recording) does not constitute disposal.
DESTRUCTION OF RECORDS
When the approved disposal date for the destruction of records has been reached, appropriate arrangements for their destruction should be made. It is the responsibility of each agency to ensure that its records are destroyed in a secure and appropriate manner as indicated in the agency Records Management Program.
UPDATING THE RECORDS DISPOSAL SCHEDULE
Records Disposal Schedules are reviewed and updated from time to time. For suggested amendments or alterations to this schedule please contact the Director of Territory Records.
ASSISTANCE IN USING THE RECORDS DISPOSAL SCHEDULE
Agencies requiring any assistance in the interpretation or implementation of any Records Disposal Schedule are encouraged to contact the Director of Territory Records.

RELATED LEGISLATION
The following legislation is related to the record classes covered by this Records Disposal Schedule: 
Copyright Act 1969(Cwlth)
Crimes Act 1900
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
Health Records (Privacy Access) Act 1997
Human Rights Commission Act 2005
Intoxicated People (Care and Protection) Act 1994
Medicines, Poisons and Therapeutic Goods Act 2008
Privacy Act 1988 (Cwlth)
Public Sector Management Act 1994
Supervised Injecting Place Trial Act 1999
Territory Records Act 2002

DEFINITIONS
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.
Appraisal
The process of evaluating business activities to:
•	determine which records need to be captured;
•	determine how long the records need to be kept to meet business needs; and
•	meet the requirements of organisational accountability and community expectations.
Business Classification Scheme
A hierarchical scheme for identifying and defining the functions, activities and transactions an agency performs in the conduct of its business, and the relationships between them.
Converted Record
The copy of the record resulting from the conversion (compare source record). For example, the digitised copy of a paper record.
Health Record
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 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.
Last Action
Last action is any event or activity carried out on a record, e.g. modifying a record, adding a record to a file, last time a client accessed a service, the last time a record was used or accessed by or on behalf of the patient, the completion of an audit, project, case, etc.
Principal Officer
The Chief Executive of an administrative unit, or its equivalent in other types of agencies.
Record
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.
Recordkeeping Systems
Information systems that capture, maintain and provide access to records over time. While the term is often associated with computer software, Recordkeeping Systems also encompass policies, procedures, practices and resources that are applied within an agency to ensure that full and accurate records of business activity are made and kept.
Records of an Agency
Records, in writing, electronic or any other form, under the control of an agency or to which it is entitled to control, kept as a record of its activities, whether it was created or received by the agency.
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.
Records Management Program
A document that complies with Section 16 of the Territory Records Act 2002 by setting out the means by which an agency will manage its records, and is approved by the agency's Principal Officer.
Scope Note
An explanation of terms used in describing the records and the context in which they were made and used.
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.
Source Record
The copy of the record that is being converted into another format (compare converted record).  For example, the paper record that is being digitised.
Territory Archives
Records preserved for the benefit of present and future generations.

BUSINESS CLASSIFICATION SCHEME

HEALTH TREATMENT AND CARE
The function of providing patient/client health care and treatment by a health service provider.  Includes individual health evaluation, diagnosis, treatment, care, progress and health outcomes of clients and patients.
Audit
The activities associated with officially checking financial, quality assurance and operational records to ensure they have been kept and maintained in accordance with agreed or legislated standards and correctly record the events, processes and business of the agency in a specified period. Includes compliance audits, financial audits, operational audits, recordkeeping audits, skills audits, system audits and quality assurance audits.
Committees
The activities associated with the managing of committees and task forces. Includes the committee's establishment, appointment of members, terms of reference, proceedings, minutes of meetings, reports, agenda etc.
Control
The activities associated with creating, maintaining and evaluating control mechanisms. Includes classification, indexing, registration, forms design etc to ensure maximum control over records and recordkeeping systems. Also includes control mechanisms for other information resources and systems.
Inventory
The activities associated with listing and preparing lists of items and assets in the possession of the agency.
Litigation
The activities involved in managing lawsuits or legal proceedings between the agency and other parties in a court or other tribunal. Includes briefs for counsel; copies of documents required by or lodged with a court; consultation with the Attorney-General and other agencies; and records documenting compliance with court instructions, e.g. subpoenas and discovery orders.
Procedures
Standard methods of operating laid down by the agency according to formulated policy.
Public Reaction
The process of handling public reaction to an agency's policies or services.  Includes anonymous letters, letters of complaint and letters of congratulations or appreciation received from the public.

Quality Assurance
The activities involved with the development, monitoring and reviewing of quality assurance programs.
Reporting
The processes associated with initiating or providing a formal response to a situation or request (either internal, external or as a requirement of corporate policies, regulation, or legislation, e.g. Annual Report).  Includes statistics and returns.
Note: Reports resulting from a routine activity, e.g. inspection reports, form part of that activity, i.e. reports resulting from an inspection are part of the inspection and not the activity of Reporting.  Reports of these types should be classified as part of the greater activity generating the report.
Research
The activities involved in investigating or enquiring into a subject or area of interest in order to discover facts, principles, etc. Used to support development of projects, standards, guidelines, etc. and business activities in general. Includes following up enquiries relating to programs, projects, working papers, literature searches, etc.
Service Provision
The activities relating to services provided by an agency on a long term basis or by other agencies. Includes requests and applications for services, assessment of eligibility and entitlements, liaison with other agencies regarding the provision of services. Also includes activities to lobby for services and to increase service provision. Also includes the installation, operation and removal of temporary facilities in parks and reserves, such as water, electricity, temporary toilets, etc. for special outdoor events.

RECORDS DISPOSAL SCHEDULE

HEALTH TREATMENT AND CARE
The function of providing patient/client health care and treatment by a health service provider.  Includes individual health evaluation, diagnosis, treatment, care, progress and health outcomes of clients and patients.
Audit
The activities associated with officially checking financial, quality assurance and operational records to ensure they have been kept and maintained in accordance with agreed or legislated standards and correctly record the events, processes and business of an agency, company or other organisation in a specified period.  Includes compliance audits, financial audits, operational audits, recordkeeping audits, skills audits, system audits and quality assurance audits.

Entry No.	Description of Records	Disposal Action	
019.013.001	Records documenting clinical audits.	Destroy 7 years after last action	
*019.013.001*			
019.013.002	Waiting Lists - Clerical audit reports.	Destroy 3 years after last action	
*019.013.002*			
Committees
The activities associated with the establishment, appointment of members, terms of reference, proceedings, minutes of meetings, reports, agendas, etc. of committees and task forces.

Entry No.	Description of Records	Disposal Action	
019.020.001	Records relating to clinical trial projects submitted to Human Research Ethics Committees for approval.
[For records documenting Human Research Ethics Committee’s and other health related committee’s meetings, use PATIENT SERVICES ADMINISTRATION – Committees.]	Destroy 7 years after date of publication or termination of the study	
*019.020.001*			

Control
The activities associated with creating, maintaining and evaluating control mechanisms. Includes classification, indexing, registration, forms design etc to ensure maximum control over records and recordkeeping systems. Also includes control mechanisms for other information resources and systems.

Entry No.	Description of Records	Disposal Action	
019.026.001	Patient Master Index or Number Register (e.g. Card Register.  If not converted to an electronic system).	Retain as Territory Archives	
*019.026.001*			
019.026.002	Disease and Operation Index.	Retain as Territory Archives	
*019.026.002*			
019.026.003	Physicians Index (If held).	Destroy 15 years after date of last entry	
*019.026.003*			
019.026.004	Admission and Discharge Registers.	Retain as Territory Archives	
*019.026.004*			
019.026.005	Registers of Births.	Retain as Territory Archives	
*019.026.005*			
019.026.006	Death Registers.	Retain as Territory Archives	
*019.026.006*			
019.026.007	Community Health Registers, including Baby Health registers.	Destroy 15 years after date of last entry or 15 years after youngest child in the register turns 18, whichever is later	
*019.026.007*			
019.026.008	Emergency Department Registers.	Retain as Territory Archives	
*019.026.008*			
019.026.009	Register of Patient Injury forms.	Destroy 30 years after date of last entry	
*019.026.009*			
019.026.010	Ward Registers.	Destroy 7 years after last action	
*019.026.010*			
019.026.011	Surgical procedures, Operation or Theatre Registers.	Retain as Territory Archives	
*019.026.011*			

Control (Continued)
The activities associated with creating, maintaining and evaluating control mechanisms. Includes classification, indexing, registration, forms design etc to ensure maximum control over records and recordkeeping systems. Also includes control mechanisms for other information resources and systems.

Entry No.	Description of Records	Disposal Action	
019.026.012	Registers of surgically implanted devices.  Includes duplicates of records of accountable items used in operating theatres e.g. instruments and swab counts where they are used as the register.	Destroy 15 years after last action	
*019.026.012*			
019.026.013	Electro-Convulsive Therapy (ECT) Register, Sedation and Seclusion Registers and Rapid Tranquillisation Journals.	Destroy 15 years after date of last entry	
*019.026.013*			
019.026.014	Duplicate registration and index records.	Destroy 6 months after last action	
*019.026.014*			
019.026.015	Inpatient Admission, Transfer and Discharge lists.
Note: Where the Admission or Discharge Register does not exist sentence in accordance with class 019.026.004.	Destroy 2 years after date of last entry	
*019.026.015*			
019.026.016	Death lists.
Note: Where a Death Register does not exist sentence in accordance with 019.026.006.	Destroy 2 years after date of last entry	
*019.026.016*			
019.026.017	Operation/Theatre lists or schedules e.g. Theatre bookings.	Destroy 2 years after list or schedule completed	
*019.026.017*			
019.026.018	Clinical lists, including outpatient lists, attendance books etc.
[For client contact details not recorded elsewhere, use 019.169.029.]	Destroy 1 year after date of last entry	
*019.026.018*			
019.026.019	Registers or control records maintained for the identification and location of diagnostic recordings and reports.	Destroy  7 years after last action	
*019.026.019*			
 
019.026.020	Registers of bodily specimens collected or received.  Includes registration details in laboratory information management systems.	Destroy in accordance with current National Pathology Accreditation Advisory Council (NPAAC) standards	
*019.026.020*			

Control (Continued)
The activities associated with creating, maintaining and evaluating control mechanisms. Includes classification, indexing, registration, forms design etc to ensure maximum control over records and recordkeeping systems. Also includes control mechanisms for other information resources and systems.

Entry No.	Description of Records	Disposal Action	
019.026.021	Extract summary data from the specimens register that is used to undertake management activities and where no data or actions are noted on that extract data.	Destroy 6 months after last action	
*019.026.021*			
019.026.022	Extract summary data from the specimens register that is used to undertake management activities and where data and/or actions are noted on that extract data but not recorded on the main register.	Destroy  3 years after last action	
*019.026.022*			
019.026.023	Registers of blood products containing details of fresh and pooled blood products.	Destroy 20 years after date of last entry	
*019.026.023*			
019.026.024	PAP Test Registers.	Destroy 15 years after date of last entry	
*019.026.024*			
019.026.025	Registers of drugs.  Includes Drugs of Dependence Registers and S4D Drug Registers held in the Pharmacy Department, Ward or other department.	Destroy 7 years after date of last entry	
*019.026.025*			
019.026.026	Patient money and valuables registers.	Destroy 7 years after date of last entry	
*019.026.026*			
019.026.027	Patient property and wearing apparel books.	Destroy 7 years after last action	
*019.026.027*			
019.026.028	Registers of patient’s admission and account forms (if maintained).	Destroy 7 years after date of last action	
*019.026.028*			
019.026.029	Registers or Logs of incoming and outgoing correspondence relating to the treatment and care of individual patients and/or clients including referrals.	Destroy 7 years after last action	
*019.026.029*			

 Inventory
The activities associated with listing and preparing lists of items and assets in the possession of the agency.

Entry No.	Description of Records	Disposal Action	
019.061.001	Stock and inventory control records.  Includes requisitions and orders for pharmaceutical products or substances and receipts/records of delivery.	Destroy 2 years after date of last entry	
*019.061.001*			
Litigation
The activities involved in managing lawsuits or legal proceedings between the agency and other parties in a court or other tribunal. Includes briefs for counsel; copies of documents required by or lodged with a court; consultation with the Attorney-General and other agencies; and records documenting compliance with court instructions, e.g. subpoenas and discovery orders.
[For litigation not related to clinical services, use LEGAL SERVICES – Litigation.
For complaints or incidents relating to clinical services not resulting in legal action, use HEALTH TREATMENT AND CARE - Public Reaction.]

Entry No.	Description of Records	Disposal Action	
019.068.001	Records relating to clinical services issues, claims or case matters involving legal action and the health facility and its patients/clients, that:
•	are of major public interest or controversy;
•	are precedent setting in nature;
•	resulted in significant changes to the service or facility's policy and/or procedures.	Retain as Territory Archives	
*019.068.001*			
019.068.002	Records relating to clinical services issues, claims or case matters involving legal action and the health facility and its patients/clients, that:
•	are not of major public interest or controversy;
•	are not precedent setting in nature;
•	did not resulting in significant changes to the service or facility’s policy and/or procedures.	Destroy 15 years after last action	
*019.068.002*			

Litigation (continued)
The activities involved in managing lawsuits or legal proceedings between the agency and other parties in a court or other tribunal. Includes briefs for counsel; copies of documents required by or lodged with a court; consultation with the Attorney-General and other agencies; and records documenting compliance with court instructions, e.g. subpoenas and discovery orders.
[For litigation not related to clinical services, use LEGAL SERVICES – Litigation.
For complaints or incidents relating to clinical services not resulting in legal action, use HEALTH TREATMENT AND CARE - Public Reaction.]

Entry No.	Description of Records	Disposal Action	

019.068.003	Subpoenas and discovery orders involving the health service or facility.
[For subpoenas and discovery orders relating to other litigation not directly involving the health service or facility, use INFORMATION MANAGEMENT – Enquiries.]	Destroy 7 years after last action	
*019.068.003*			
Procedures
Standard methods of operating laid down by the agency according to formulated policy.

Entry No.	Description of Records	Disposal Action	
019.082.001	Records relating to the Pathology Laboratory’s services approved methodologies, standard procedures and methods for the conduct of tests and medical procedures.	Destroy 15 years after method or procedure superseded	
*019.082.001*			

Public Reaction
The process of handling public reaction to an agency's policies or services.  Includes anonymous letters, letters of complaint and letters of congratulations or appreciation received from the public.
[For complaints or incidents resulting in legal action, use Litigation.]

Entry No.	Description of Records	Disposal Action	
019.084.001	Records documenting complaints and incidents, including those investigated by the Health Services Commissioner, not involving legal action, which resulted in significant changes to services, policies, procedures or involved significant public or political interest.	Retain as Territory Archives	
*019.084.001*			
019.084.002	Records documenting complaints and incidents, including complaints and incidents, including those  investigated by the Health Services Commissioner, not involving legal action or with no significant public or political interest.	Destroy 7 years after last action	
*019.084.002*			
Quality Assurance
The activities involved with the development, monitoring and reviewing of quality assurance programs.

Entry No.	Description of Records	Disposal Action	
019.085.001	Records relating to the certification, implementation and audit of Pathology Laboratory processes and services.  This includes quality control and quality assurance records.	Destroy 3 years after last action	
*019.085.001*			

Reporting
The processes associated with initiating or providing a formal response to a situation or request (either internal, external or as a requirement of corporate policies, regulation, or legislation, e.g. Annual Report).  Includes statistics and returns.
Note: Reports resulting from a routine activity, e.g. inspection reports, form part of that activity, i.e. reports resulting from an inspection are part of the inspection and not the activity of Reporting.  Reports of these types should be classified as part of the greater activity generating the report.
[For the Annual Report drafting process, use PUBLICATIONS - Drafting.
For submissions of annual reports to the Portfolio Minister, use GOVERNMENT RELATIONS - Compliance.]

Entry No.	Description of Records	Disposal Action	
019.088.001	Original copies of data collection forms, including midwife data collection, admitted patient statistics, brain injury, etc. submitted by hospitals and held by the Public Health Agency.	Destroy 6 months after last action	
*019.088.001*			
019.088.002	Copies of data collection forms retained after submission of originals, held by hospitals or submitting health facilities.	Destroy 3 years after submission date	
*019.088.002*			
019.088.003	Copies of reports and records held by the notifier, (e.g. public hospitals), of notifiable diseases for patients over 18 years of age.	Destroy 15 years after last action	
*019.088.003*			

 019.088.004	Copies of reports and records held by the notifier, (e.g. public hospitals), of notifiable diseases for patients less than 18 years of age.	Destroy after the patient reaches the age of 25 years	
*019.088.004*			

Reporting (Continued)
The processes associated with initiating or providing a formal response to a situation or request (either internal, external or as a requirement of corporate policies, regulation, or legislation, e.g. Annual Report).  Includes statistics and returns.
Note: Reports resulting from a routine activity, e.g. inspection reports, form part of that activity, i.e. reports resulting from an inspection are part of the inspection and not the activity of Reporting.  Reports of these types should be classified as part of the greater activity generating the report.
[For the Annual Report drafting process, use PUBLICATIONS - Drafting.
For submissions of annual reports to the Portfolio Minister, use GOVERNMENT RELATIONS - Compliance.]

Entry No.	Description of Records	Disposal Action	
019.088.005	Records held by Public Health Units documenting the notification of notifiable diseases.  Including patient information records collected during an environmental health investigation of an outbreak of a notifiable disease.	Destroy 7 years after receipt of the notification	
*019.088.005*			

019.088.006	Copies of Cancer notification forms held by a hospital or notifying facility.	Destroy 2 years after submission 	
*019.088.006*			
019.088.007	Copies of death certificates retained separately from the main patient record.	Destroy 1 year after date of notification	
*019.088.007*			

019.088.008	Duplicate records of notifications received by Public Health Units subsequent to the initial notification.	Destroy 6 months after last action	
*019.088.008*			

019.088.009	Extracted electronic data from existing source systems which is aggregated for reporting, analysis and service planning purposes, (e.g. ACT Health Enterprise Information Management (ACTHEIM)).	Destroy 3 years after last action	
*019.088.009*			

Research
The activities involved in investigating or enquiring into a subject or area of interest in order to discover facts, principles, etc.  Used to support development of projects, standards, guidelines, etc. and business activities in general.  Includes following up enquiries relating to programs, projects, working papers, literature searches, etc.
[For records relating to the evaluation of treatments, medicines, etc. implemented because of research trial results, use PATIENT SERVICES ADMINISTRATION – Evaluation.
For records relating to population health care management and control programs and strategies research, use POPULATION HEALTH CARE MANAGEMENT AND CONTROL – Research.]

Entry No.	Description of Records	Disposal Action	
019.091.001	Records relating to the conduct of clinical and non-clinical research considered significant to the Territory or is unique, precedent setting or results in major breakthroughs in treatments or medicines.  Includes records or documentation relating to the recruitment and consent of research participants, the collection and analysis of data, preliminary findings, surveys and results.  	Retain as Territory Archives	
*019.091.001*			
019.091.002	Records relating to the conduct of clinical research not considered significant to the Territory.  Including records or documentation relating to the collection of data, data analysis, preliminary findings, surveys and results.	Destroy 15 years after last action or date of publication of the research whichever is the later	
*019.091.002*			
019.091.003	Records relating to the conduct of non-clinical research not considered significant to the Territory.  Including records or documentation relating to the collection of data, data analysis, preliminary findings, surveys and results.	Destroy 7 years after last action or date of publication of the research whichever is the later	
*019.091.003*			
019.091.004	Records relating to clinical and non-clinical research where the research did not proceed.	Destroy 3 years after last action	
*019.091.004*			

Service Provision
The activities relating to services provided by an agency on a long term basis or by other agencies. Includes requests and applications for services, assessment of eligibility and entitlements, liaison with other agencies regarding the provision of services. Also includes activities to lobby for services and to increase service provision. Also includes the installation, operation and removal of temporary facilities in parks and reserves, such as water, electricity, temporary toilets, etc. for special outdoor events.

Entry No.	Description of Records	Disposal Action	
019.169.001	Records documenting the initial diagnosis of a genetic or inherited disorder in patients/clients.	Retain as Territory Archives	
*019.169.00			
019.169.002	Records of discharged in-patients, including deceased in-patients over 18 years of age who received acute hospital care.  Excludes Records on:
•	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
•	Radiotherapy treatment, see 019.169. 024	Destroy 15 years after last action	
*019.169.00			
019.169.003	Records of discharged in-patients, including deceased in-patients less than 18 years of age who received acute hospital care.  Excludes Records on:
•	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
•	Radiotherapy treatment, see 019.169. 024	Destroy 15 years after the patient reaches the age of 18 years or 15 years after last action whichever is later
	
*019.169.003*			
019.169.004	Records of patients attending or presenting to Emergency Departments and not admitted as in-patients over 18 years of age.  Includes patients who are dead on arrival (DOA) and records contained in the Emergency Department Information System (EDIS).	Destroy 7 years after last action	
*019.169.004*			

Service Provision (Continued)
The activities relating to services provided by an agency on a long term basis or by other agencies. Includes requests and applications for services, assessment of eligibility and entitlements, liaison with other agencies regarding the provision of services. Also includes activities to lobby for services and to increase service provision. Also includes the installation, operation and removal of temporary facilities in parks and reserves, such as water, electricity, temporary toilets, etc. for special outdoor events.

Entry No.	Description of Records	Disposal Action	
019.169.005	Records of patients attending or presenting to Emergency Departments and not admitted as in-patients, less than 18 years of age.  Includes patients who are dead on arrival (DOA) and records contained in the Emergency Department Information System (EDIS).	Destroy 7 years after the patient reaches the age of 18  years or 7 years after last action whichever is later	
*019.169.005*			
019.169.006	Records of discharged patients of Extended Care or Non-acute Care Facilities over 18 years of age.  Includes records of residents of establishments registered under the Aged Care Act 1997.  Also includes patients who die while in or receiving treatment from a facility.	Destroy 10 years after last action	
*019.169.006*			
019.169.007	Records of discharged patients of Extended Care or Non-acute Care Facilities less than 18 years of age.  Includes records of patients who die while in or receiving treatment from a facility.	Destroy 10 years after the patient reaches the age of 18 years or 10 years after last action whichever is later	
*019.169.007*			
019.169.008	Records of non-admitted patients over 18 years of age.  Includes those attending Hospital Outpatient Departments or clinics or receiving Community based care or non-admitted patients of day hospitals, day centres, community care 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 Records, Immunisation Records, Child/Baby health care screening, School Screening records and Oral or Dental health care non-admitted records.	Destroy 7 years after last action	
*019.169.008*			

Service Provision (Continued)
The activities relating to services provided by an agency on a long term basis or by other agencies. Includes requests and applications for services, assessment of eligibility and entitlements, liaison with other agencies regarding the provision of services. Also includes activities to lobby for services and to increase service provision. Also includes the installation, operation and removal of temporary facilities in parks and reserves, such as water, electricity, temporary toilets, etc. for special outdoor events.

Entry No.	Description of Records	Disposal Action	
019.169.009	Health Records of non admitted patients under the age of 18 years. Includes those attending Hospital Outpatient Departments or clinics or receive community based care or non-admitted patients of day hospitals, day centres, community care 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 Records, Immunisation Records, Child/Baby health care screening, School Screening records and Oral or Dental health care non-admitted records.	Destroy 7 years after the patient reaches the age of 18 years or 7 years after last action whichever is later	
*019.169.009*			
019.169.010	Obstetric/maternal health care records documenting birth episodes (mother’s record).  	Retain as Territory Archives  	
*019.169.010*			
019.169.011	Records documenting child/baby birth episodes.	Retain as Territory Archives  	
*019.169.011*			
019.169.012	Obstetric/maternal social work records relating to instances of arrangements for adoption.  Includes both maternal and child (subject of adoption) records.  	Retain as Territory Archives 	
*019.169.012*			
019.169.013	Records of patients/clients receiving psychiatric treatment and mental health care under the Mental Health (Treatment and Care) Act 1994 where the patient/client is over 18 years of age.  	Destroy 15 years after last action	
*019.169.013*			
019.169.014	Records of patients/clients receiving psychiatric treatment and mental health care under the Mental Health (Treatment and Care) Act 1994 where the patient/client is less than 18 years of age.	Destroy 15 years after the patient reaches the age of 18 years or 15 years after last action whichever is later	
*019.169.014*			

Service Provision (Continued)
The activities relating to services provided by an agency on a long term basis or by other agencies. Includes requests and applications for services, assessment of eligibility and entitlements, liaison with other agencies regarding the provision of services. Also includes activities to lobby for services and to increase service provision. Also includes the installation, operation and removal of temporary facilities in parks and reserves, such as water, electricity, temporary toilets, etc. for special outdoor events.

Entry No.	Description of Records	Disposal Action	
019.169.015	Records documenting Assisted Reproductive Technology (ART) procedures (including In Vitro Fertilisation, gamete intrafallopian transfer (GIFT) and artificial insemination) where a pregnancy is achieved, whether a child was born or not or it is not known whether a child was born.  This includes case records of each individual person or family unit, consent to ART procedures, use of semen, ova or embryos and the withdrawal of consent for such procedures or processes.	Destroy 75 years after date of birth of the child or date of insemination if the date of birth is unknown	
*019.169.015*			
019.169.016	Records relating to Assisted Reproductive Technology (ART) where a pregnancy was not achieved or the procedure was terminated.	Destroy 15 years after last action	
*019.169.016*			
019.169.017	Records documenting patients who were the victim of sexual assault who were over 18 years of age.	Destroy 75 years after date of birth of patient	
*019.169.017*			
019.169.018	Records documenting patients who were the victim of sexual assault who were less than 18 years of age.	Destroy 75 years after date of birth of patient	
*019.169.018*			
019.169.019	Records relating to clients of the Child at Risk Health Unit.	Destroy 75 years after date of birth of patient	
*019.169.019*			
019.169.020	Requests/referrals for patients over the age of 18 received for services, where the patient did not attend and no service was provided. Includes request for Admission Forms where the patient did not attend. 	Destroy 7 years after last action
	
*019.169.00*			

Service Provision (Continued)
The activities relating to services provided by an agency on a long term basis or by other agencies. Includes requests and applications for services, assessment of eligibility and entitlements, liaison with other agencies regarding the provision of services. Also includes activities to lobby for services and to increase service provision. Also includes the installation, operation and removal of temporary facilities in parks and reserves, such as water, electricity, temporary toilets, etc. for special outdoor events.

Entry No.	Description of Records	Disposal Action	
019.169.021	Requests/referrals for patients under the age of 18 received for services, where the patient did not attend and no service was provided. Includes request for Admission Forms where the patient did not attend.	Destroy 7 years after the patient reaches the age of 18 or 7 years after last action whichever is later	
*019.169.01*			

019.169.022	Medical certificates issued to patients who were over 18 years of age detailing dates of attendance and where appropriate reason for attendance.	Destroy 7 years after last action	
*019.169.02*			
019.169.023	Medical certificates issued to patients who were less than 18 years of age detailing dates of attendance and where appropriate reason for attendance.	Destroy after the patient reaches the age of 25 years	
*019.169.03*			
019.169.024	Records documenting radiation planning, treatment and dose delivery in respect to patients, admitted and non-admitted, who have undergone radiotherapy treatment.  Includes Dosimetry and calculation data, Tech data and Images. Localisation, portal, EPID image proprietary digital format.	Destroy 7 years after death of patient or 7 years after patient would have reached age 70 or 7 years after last action whichever is the later	
*019.169.024*			
019.169.025	Sterilisation Print-outs relating to sterilisation of medical equipment.  Excludes dental equipment.
[For dental equipment, use HEALTH TREATMENT AND CARE – Service Provision, class 019.169.058.]	Destroy 15 years after date of print-out	
*019.169.029*			
019.169.026	Log Books/Sterilisation Register (if kept) of steriliser’s performance.	Destroy 15 years after date of last entry	
*019.169.026*			
019.169.027	Records relating to the management, treatment and care of patients over 18 years of age on the ward not incorporated into the main (unit) patient record, (e.g. group education sessions for pregnant women, Ward reports, Ward report books and related records).	Destroy 7 years after date of last entry	
*019.169.027*			

Service Provision (Continued)
The activities relating to services provided by an agency on a long term basis or by other agencies. Includes requests and applications for services, assessment of eligibility and entitlements, liaison with other agencies regarding the provision of services. Also includes activities to lobby for services and to increase service provision. Also includes the installation, operation and removal of temporary facilities in parks and reserves, such as water, electricity, temporary toilets, etc. for special outdoor events.

Entry No.	Description of Records	Disposal Action	
019.169.028	Records relating to the management, treatment and care of patients less than 18 years of age on the ward not incorporated into the main (unit) patient record, (e.g. group education sessions for pregnant women, Ward reports, Ward report books and related records).	Destroy 7 years after the patient reaches the age of 18 years or 7 years after the last action whichever is later	
*019.169.028*			
019.169.029	Personal clinician/work diaries or appointment books/registers recording details of appointments and client contact not recorded elsewhere.	Destroy 15 years after date of last entry	
*019.169.029*			
019.169.030	Diaries/appointment books used to record basic information/registers such as dates and times of meetings and appointments.	Destroy 6 months after last action	
*019.169.030*			
019.169.031	Medical officer’s requests for a diagnostic imaging procedure.	Destroy 3 years after last action	
*019.169.031*			

019.169.032	Originals or copies of diagnostic reports or findings of records or reports resulting from diagnostic findings based on an analysis, evaluation or interpretation of recordings maintained by the diagnostic service.	Destroy 3 years after last action	
*019.169.032*			
019.169.033	Visual/image/pictorial recordings produced for diagnostic purposes of patients over 18 years of age.  Includes x-rays, videotapes, films, photographs or equivalent image recordings.	Destroy 7 years after last action	
*019.169.033*			
019.169.034	Visual/image/pictorial recordings produced for diagnostic purposes of patients less than 18 years of age.  Includes x-rays, videotapes, films, photographs or equivalent image recordings.	Destroy 7 years after the patient reaches the age of 18 years or 7 years after last action whichever is later	
*019.169.034*			

Service Provision (Continued)
The activities relating to services provided by an agency on a long term basis or by other agencies. Includes requests and applications for services, assessment of eligibility and entitlements, liaison with other agencies regarding the provision of services. Also includes activities to lobby for services and to increase service provision. Also includes the installation, operation and removal of temporary facilities in parks and reserves, such as water, electricity, temporary toilets, etc. for special outdoor events.

Entry No.	Description of Records	Disposal Action	
019.169.035	Graphical recordings or tracings of a graphical nature for patients over 18 years of age, created via diagnostic measuring processes, (e.g. Electroencephalograms, Electrocardiograms, Electromyograms or Cardiotocogram).	Destroy 7 years after last action	
*019.169.035*			
019.169.036	Graphical recordings or tracings of a graphical nature for patients less than 18 years of age, created via diagnostic measuring processes, (e.g. Electroencephalograms, Electrocardiograms, Electromyograms or Cardiotocogram).	Destroy 7 years after the patient reaches the age of 18 years or 7 years after last action whichever is later	
*019.169.036*			

019.169.037	Copies of requests for Laboratory tests or procedures held by the Diagnostic Service.	Destroy 3 years after last action	
*019.169.037*			
019.169.038	Diagnostic results and reports resulting from Anatomical pathology, cytology (Exfoliate and Non-exfoliate), autopsy/ post mortem reports/records/registers/diagrams, histopathology and bone marrow reports/records, including copies of any representative images prepared.	Destroy 20 years after last action	
*019.169.038*			
019.169.039	Other diagnostic results and pathology reports/records of patients over 18 years of age.  Includes cytology, bone marrow, histopathology, clinical chemistry, chemical pathology, microbiology and immunology reports/records.	Destroy 7 years after last action	
*019.169.039*			
019.169.040	Other diagnostic results and pathology reports/records of patients less than 18 years of age.  Includes cytology, bone marrow, histopathology, clinical chemistry, chemical pathology, microbiology and immunology reports/records.	Destroy 7 years after the patient reaches the age of 18 years or 7 years after last action whichever is later	
*019.169.040*			

Service Provision (Continued)
The activities relating to services provided by an agency on a long term basis or by other agencies. Includes requests and applications for services, assessment of eligibility and entitlements, liaison with other agencies regarding the provision of services. Also includes activities to lobby for services and to increase service provision. Also includes the installation, operation and removal of temporary facilities in parks and reserves, such as water, electricity, temporary toilets, etc. for special outdoor events.

Entry No.	Description of Records	Disposal Action	
019.169.041	Diagnostic genetics reports/records.  Including karyotypes and digital images.	Retain as Territory Archives 	
*019.169.041*			
019.169.042	Records documenting the management of patient finances including accounts, benefits and claims, hospital private patient claim and assignment forms (hc21), patient election forms and authorities to make payment or transfer property.	Destroy 7 years after last action	
*019.169.042*			

019.169.043	Assigned benefits claim books (if maintained).	Destroy 1 year after last action	
*019.169.043*			
019.169.044	Bodily specimens, samples or materials examined in a diagnostic pathology procedures. Includes slides, films, blocks, cultures and related material.	Destroy in accordance with current National Pathology Accreditation Advisory Council (NPAAC) standards	
*019.169.044*			
019.169.045	Records associated with the management and consent in respect to retained human tissue samples. The types of records include statutory declarations, consent forms and clinical information about the deceased etc.	Destroy 20 years after disposal of tissue	
*019.169.045*			

019.169.046	Diagnostic results and reports relating to blood and blood products.	Destroy 10 years after last action or after donor reaches the age of 30 years whichever is longer	
*019.169.046*			

Service Provision (Continued)
The activities relating to services provided by an agency on a long term basis or by other agencies. Includes requests and applications for services, assessment of eligibility and entitlements, liaison with other agencies regarding the provision of services. Also includes activities to lobby for services and to increase service provision. Also includes the installation, operation and removal of temporary facilities in parks and reserves, such as water, electricity, temporary toilets, etc. for special outdoor events.

Entry No.	Description of Records	Disposal Action	
019.169.047	Laboratory records documenting the administration of blood and blood products.	Destroy 20 years after last action or after donor reaches the age of 30 years whichever is longer  	
*019.169.047*			
019.169.048	Records relating to the business of semen supply, including full name and date of birth of donor, donor’s written consent, results of tests and name of the medical practitioner to whom semen was supplied.	Destroy 10 years after last action or after donor reaches the age of 30 years whichever is longer	
*019.169.048*			

019.169.049	Records relating to the supply of Cytotoxic Drugs, including prescriptions and records of supply.	Destroy 2 years after dispensing	
*019.169.049*			
019.169.050	Records relating to the supply of Drugs of Dependence including prescriptions and records of supply.	Destroy 7 years after dispensing	
*019.169.050*			
019.169.051	Pharmacy copies of inpatient prescriptions.	Destroy 7 days after date of dispensing 	
*019.169.051*			
019.169.052	Pharmacy copies of Intravenous additives prescriptions and manufacturing records.	Destroy 2 years after dispensing	
*019.169.052*			
019.169.053	Records relating to outpatient prescriptions and records of supply.	Destroy 2 years after dispensing	
*019.169.053*			

019.169.054	Records relating to S100 prescriptions and records of supply.	Destroy 7 years after dispensing	
*019.169.054*			
019.169.055	Records relating to the provision, coordination and maintenance of the ACT Equipment Scheme (ACTES) and the Home and Community Care (HACC) Equipment Scheme services.	Destroy 7 years after the patient reaches the age of 18 years or 7 years after last action whichever is later	
*019.169.055*			

Service Provision (Continued)
The activities relating to services provided by an agency on a long term basis or by other agencies. Includes requests and applications for services, assessment of eligibility and entitlements, liaison with other agencies regarding the provision of services. Also includes activities to lobby for services and to increase service provision. Also includes the installation, operation and removal of temporary facilities in parks and reserves, such as water, electricity, temporary toilets, etc. for special outdoor events.

Entry No.	Description of Records	Disposal Action	
019.169.056	Applications for aids, appliances and services from the ACT Equipment Loan Service, ACT Equipment Scheme (ACTES) and/or the Home and Community Care (HACC) Equipment Scheme.	Destroy 7 years after the patient reaches the age of 18 years or 7 years after last action whichever is later	
*019.169.056*			
019.169.057	Applications for access to patient records, including a child’s record.  Includes requests from insurers or other third parties with written patient consent to access the patient’s clinical records.	Destroy 2 years after last action	
*019.169.057*			
019.169.058	Sterilisation Print-outs relating to sterilisation of dental equipment.
[For all other medical equipment, use HEALTH TREATMENT AND CARE – Service Provision, class 019.169.025.]	Destroy 7 years after date of print-out	
*019.169.058*			

RETAIN AS TERRITORY ARCHIVES

HEALTH TREATMENT AND CARE
The function of providing patient/client health care and treatment by a health service provider.  Includes individual health evaluation, diagnosis, treatment, care, progress and health outcomes of clients and patients.
Control
The activities associated with creating, maintaining and evaluating control mechanisms. Includes classification, indexing, registration, forms design etc to ensure maximum control over records and recordkeeping systems. Also includes control mechanisms for other information resources and systems.

Entry No.	Description of Records	Disposal Action	
019.026.001	Patient Master Index or Number Register. (e.g. Card Register.  If not converted to an electronic system).	Retain as Territory Archives	
*019.026.001*			
019.026.002	Disease and Operation Index.	Retain as Territory Archives	
*019.026.002*			
019.026.004	Admission and Discharge Registers.	Retain as Territory Archives	
*019.026.004*			
019.026.005	Registers of Births.	Retain as Territory Archives	
*019.026.005*			
019.026.006	Death Registers.	Retain as Territory Archives	
*019.026.006*			
019.026.008	Emergency Department Registers.	Retain as Territory Archives	
*019.026.008*			
019.026.011	Surgical procedures, Operation or Theatre Registers.	Retain as Territory Archives	
*019.026.011*			

Litigation
The activities involved in managing lawsuits or legal proceedings between the agency and other parties in a court or other tribunal. Includes briefs for counsel; copies of documents required by or lodged with a court; consultation with the Attorney-General and other agencies; and records documenting compliance with court instructions, e.g. subpoenas and discovery orders.
[For complaints or incidents not resulting in legal action, use Public Reaction.]

Entry No.	Description of Records	Disposal Action	
019.068.001	Records relating to issues, claims or case matters involving legal action and the health facility and its patients/clients, that are of major public interest or controversy; which is precedent-setting in nature; or resulting in significant changes to the service or facility’s policy and/or procedures.	Retain as Territory Archives	
*019.068.001*			
Public Reaction
The process of handling public reaction to an agency's policies or services.  Includes anonymous letters, letters of complaint and letters of congratulations or appreciation received from the public.
[For complaints or incidents resulting in legal action, use Litigation.]

Entry No.	Description of Records	Disposal Action	
019.084.001	Records documenting complaints and incidents investigated by the Health Services Commissioner, not involving legal action, which resulted in significant changes to services, policies, procedures or involved significant public or political interest.	Retain as Territory Archives	
*019.084.001*			
Research
The activities involved in investigating or enquiring into a subject or area of interest in order to discover facts, principles, etc.  Used to support development of projects, standards, guidelines, etc. and business activities in general.  Includes following up enquiries relating to programs, projects, working papers, literature searches, etc.

Entry No.	Description of Records	Disposal Action	
019.091.001	Records relating to the conduct of clinical and non-clinical research considered significant to the Territory or is unique, precedent setting or results in major breakthroughs in treatments or medicines.	Retain as Territory Archives	
*019.091.001*			
Service Provision
The activities relating to services provided by an agency on a long term basis or by other agencies. Includes requests and applications for services, assessment of eligibility and entitlements, liaison with other agencies regarding the provision of services. Also includes activities to lobby for services and to increase service provision. Also includes the installation, operation and removal of temporary facilities in parks and reserves, such as water, electricity, temporary toilets, etc. for special outdoor events.

Entry No.	Description of Records	Disposal Action	
019.169.001	Records documenting the initial diagnosis of a genetic or inherited disorder in patients/clients.	Retain as Territory Archives	
*019.169.00			
019.169.010	Obstetric/maternal health care records documenting birth episodes (mother’s record).  	Retain as Territory Archives  	
*019.169.010*			
019.169.011	Records documenting child/baby birth episodes.	Retain as Territory Archives  	
*019.169.011*			
019.169.012	Obstetric/maternal social work records relating to instances of arrangements for adoption.  Includes both maternal and child (subject of adoption) records.  	Retain as Territory Archives 	
*019.169.012*			
019.169.041	Diagnostic genetics reports/records.  Including karyotypes and digital images.	Retain as Territory Archives 	
*019.169.043*			

INDEX

A
Access requests from insurers	35
Access requests from third parties	35
Access to patient records	35
Accounts	33
ACT Equipment Loan Service	35
ACT Equipment Scheme (ACTES)	34, 35
Acute hospital care	26, 27
Administration of blood and blood products	34
Admission and account forms	19
Admission and Discharge Registers	17, 37
Admission Forms	29, 30
Admitted patient statistics	23
Adoption	28, 39
Aids	35
Anatomical pathology	32
Appliances	35
Appointment books/registers	31
Appointments	31
Approved methodologies	21
Artificial insemination	29
Assisted Reproductive Technology (ART)	29
Attendance books	18
Audit of processes and services	22
Audit reports	16
Authorities to make payment	33
Authorities to transfer property	33
Autopsy/ post mortem reports	32
B
Baby Health registers	17
Benefits and claims	33
Benefits claim books	33
Blocks	33
Blood and blood products	33
Blood products	19
Bodily specimens	18
Bodily specimens	33
Brain injury	23
C
Cancer notification forms	24
Card Register	17, 37
Cardiotocogram	32
Central Cancer Registry	24
Certification	22
Child at risk	26
Child at Risk	29
Child at Risk Health Unit	29
Child/Baby health care screening	27, 28
Clerical audit reports	16
Clinical and non-clinical research	25, 38
Clinical audits	16
Clinical information about the deceased	33
Clinical lists	18
Clinical research	25
Clinical trial	16
Collection of data	25
Community based care	28
Community based care	27
Community Health Registers	17
Community Records	27, 28
Complaints	22, 38
Consent forms	33
Control records	18
Controversy	38
Controversy	20
Cultures	33
Cytology (Exfoliate and Non-exfoliate)	32
Cytotoxic Drugs	34
D
Data analysis	25
Data collection forms	23
Day centres	27, 28
Day hospitals	27, 28
Dead on arrival	26, 27
Death certificates	24
Death lists	18
Death Registers	17, 37
Dental Equipment	35
Dental health care	27, 28
Diagnosis	26, 39
Diagnostic findings	31
Diagnostic genetics reports/records	33, 39
Diagnostic imaging	31
Diagnostic pathology procedures	33
Diagnostic recordings	18
Diagnostic reports	18, 31
Diagnostic results and pathology reports/records	32
Diagnostic results and reports	32, 33
Diagnostic service	31
Diagnostic Service	32
Diaries/appointment books	31
Digital images	33, 39
Discharged in-patients	26
Discovery orders	21
Disease and Operation Index	17, 37
Domiciliary care services	27, 28
Dosimetry	30
Drugs of Dependence	34
Drugs of Dependence Registers	19
Duplicate registration and index records	18
E
Electrocardiograms	32
Electro-Convulsive Therapy (ECT) Register	18
Electroencephalograms	32
Electromyograms	32
Embryos	29
Emergency Department Information System (EDIS).	26, 27
Emergency Department Registers	17, 37
Emergency Departments	26, 27
Environmental health investigation	24
EPID image	30
Ethics Committees	16
Extended Care Facilities	27
Extract summary	19
F
Films	31, 33
G
Gamete intrafallopian transfer (GIFT)	29
Genetic or inherited disorder	26, 39
Genetic or inherited disorders	28, 39
Genetic or inherited disorders	26
Graphical recordings	32
Group education sessions for pregnant women	30, 31
H
Health facility	38
Health facility	20
Health Services Commissioner	22, 38
Histopathology and bone marrow reports	32
Home and Community Care	34, 35
Home and Community Care (HACC) Equipment Scheme	34, 35
Hospital Outpatient Departments	27, 28
Hospital private patient claim and assignment forms	33
Human Research Ethics Committees	16
Human tissue	33
I
Image recordings	31
Immunisation Records	27, 28
Implanted devices	18
In Vitro Fertilisation	29
Incidents	22, 38
Information/registers	31
Inpatient Admission, Transfer and Discharge lists	18
Inpatient prescriptions	34
Intravenous additives	34
Inventory	20
K
Karyotypes	33, 39
L
Laboratory information management systems	18
Laboratory records	34
Legal action	38
Legal action	20
Log Books/Sterilisation Register	30
M
Medical certificates	30
Mental health care	28
Methods for the conduct of tests and medical procedures	21
Midwife data collection	23
Money	19
Money and valuables registers	19
N
National Pathology Accreditation Advisory Council	18, 33
Non admitted patients	28
Non-acute Care Facilities	27
Non-clinical research	25
Notifiable diseases	23, 24
Notifications	24
NPAAC	18, 33
Number Register	17, 37
O
Obstetric/maternal health	26, 28, 39
Obstetric/maternal health care records	28, 39
Obstetric/maternal social work records	28, 39
Operation Registers	17, 37
Operation/Theatre lists	18
Oral or Dental health	27, 28
Orders	20
Outpatient lists	18
Outpatient prescriptions	34
Outpatients records of supply	34
P
PAP Test Register	19
Patient election forms	33
Patient finances	33
Patient Injury forms	17
Patient Master Index	17, 37
Patient money	19
Patient property books	19
Patient’s admission	19
Personal/work diaries	31
Pharmaceutical products	20
Photographs	31
Physicians Index	17
Pooled blood products	19
Precedent setting	20
Precedent-setting	38
Pregnancy	29
Prescriptions and manufacturing records	34
Prescriptions and records of supply	34
Procedures	21
Psychiatric treatment	28
Public Health Units	24
Q
Quality assurance	22
Quality control	22
R
Radiation dose delivery	30
Radiation planning	30
Radiation treatment	30
Radiotherapy treatment	30
Radiotherapy treatment	26
Rapid Tranquillisation Journals	18
Receipts/records of delivery	20
Register of surgically implanted devices	18
Registers of Births	17, 37
Registers of drugs	19
Requests	31
Requests for test or procedures	32
Requests/referrals	29, 30
Requisitions	20
Research	16
Retained human tissue	33
S
S100 prescriptions	34
S100 records of supply	34
S4D Drug Registers	19
School Screening records	27, 28
Sedation and Seclusion Registers	18
Semen	29, 34
Semen supply	34
Sexual assault	23, 29
Sexual assault care	26
Slides	33
Specimens	18
Specimens register	19
Standard procedures	21
Statutory declarations	33
Sterilisation Print-outs	30, 35
Stock	20
Subpoenas	21
Surgical procedures	17, 37
Surgically implanted devices	18
T
Tech data and Images	30
Theatre bookings	18
Theatre Registers	17, 37
Tracings	32
Transfer and Discharge lists	18
U
Unregistered clients	27, 28
V
Valuables	19
Videotapes	31
Visitors	27, 28
Visual/image/pictorial recordings	31
W
Waiting Lists	16
Ward	30, 31
Ward Registers	17
Ward report books	30, 31
Ward reports	30, 31
Wearing apparel books	19
X
X-rays	31