DGD14-022
Administrative Records Management Policy
Policy Statement
The Territory Records Act 2002 requires ACT agencies to have, and comply, with a Records
Management Program. This policy outlines the Records Management Program for ACT
Health’s administrative records and details how ACT Health will adhere to the requirements
of the Act.
The Records Management Program must comply with the Standards and codes associated
with the Act and consist of:
 The Approval of the Principal Officer
 An Administrative Records Management Policy
 An Administrative Recordkeeping Manual (accessible via ACT Health records
management intranet page).
ACT Health’s administrative records are to be managed in accordance with:
 The organisation’s need to comply with ACT Territory Records Act 2002 legislation; to
manage the creation, keeping, protection, preservation, storage and disposal of its
records, and ensure that the records are usable and accessible for as long as they are
required for official and public purposes.
Purpose
Full and accurate records
The making and keeping of full and accurate records of ACT Health’s activities is essential to
attain its stated outcomes. It is essential therefore for all staff to make and keep full and
accurate records of their activities, to ensure that such records are incorporated into
ACT Health’s recordkeeping system and to comply with all records management procedures.
Ownership of records
All records made or received by ACT Health are the corporate property of the agency. All
records that staff make, receive and maintain as part of their duties belong to ACT Health
and no records belong to individual employees. ACT Health retains control of all records
required for service delivery in accordance with Recordkeeping and Outsourced Government
Business, and ownership of records and/or the intellectual property they contain, is clearly
specified in every outsourcing contract.
Agency recordkeeping requirements
ACT Health makes, manages and keeps records to support its business needs, legal and
regulatory obligations, and broader community expectations. An analysis of these
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Review Date
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requirements and an outline of the types of records that ACT Health must make and keep
are provided in the Administrative Recordkeeping Manual.
Scope
This policy applies to all staff within ACT Health and external agencies working on behalf of
ACT Health, including, but not limited to, students, contractors and volunteers.
This policy is supported by ACT Health’s Administrative Recordkeeping Manual which
outlines the records management procedures for ACT Health administrative records. It
details the way all staff in ACT Health will make, modify, use, handle and care for records,
how, and for how long records will be kept, and how access to them will be provided.
ACT Health will only meet the requirements of the Territory Records Act 2002 if all staff
follow the procedures. Therefore adherence to the requirements of both this Policy and the
Administrative Recordkeeping Manual is obligatory for all staff.
Excluded from this policy are ACT Health clinical records which are addressed under the
‘Clinical Records Management’ policy, in conjunction with associated standard operating
procedures (SOPs) and supported by the Clinical Records Management Manual.
Roles & Responsibilities
All staff of ACT Health have recordkeeping responsibilities.
Director General
The Director General of ACT Health is in charge of records management and is responsible
for ensuring:
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compliance with all parts of ACT Health’s Records Management Program; and
that all parts of ACT Health’s Records Management Program are kept updated to reflect
all recordkeeping requirements that ACT Health must meet.
The Director General may also initiate a review of this policy at an earlier date if
circumstances make it appropriate to do so. Circumstances that would be likely to make
such a review appropriate include a major change in the functions of ACT Health or
significant administrative change in it.
Executive Director, Business and Infrastructure
The Executive Director, Business and Infrastructure, is the Executive responsible and
accountable to the Director-General, for administrative oversight of ACT Health’s
administrative recordkeeping system, including:
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compliance with external Records Management standards;
the implementation of internal recordkeeping practices;
ensure all personnel are aware of their individual responsibilities to create and keep
records in corporate recordkeeping systems in accordance with the agency’s Records
Management Program;
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ensuring that recordkeeping systems underpin and support business processes;
the appointment of a Records Manager to manage the day-to-day records management
of the agency;
where necessary, the creation of a Records Management Unit to assist the Records
Manager;
the Records Management Unit is responsible for the physical creation of ACT Health’s
Administrative records;
approval of Procedures that are included in the agency’s Records Management Program;
ensuring new and existing personnel under their control undertake recordkeeping
awareness training;
ensuring full and accurate records of business activities are made and kept;
developing performance measures for evaluation and implement actions, to meet
corporate objectives and relevant standards and;
reviewing and updating the Records Management Program on a rolling basis such that
the entire program is reviewed and updated at least every five years.
Managers and Supervisors
Managers and supervisors are accountable for compliance with the records management
policy and procedures, as set out in the ACT Health Administrative Recordkeeping Manual in
their area of responsibility, for both paper and digital records. Managers and supervisors are
responsible for:
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induction of new and existing personnel about their responsibilities under the legislation,
agency policies and Records Management Program,
recordkeeping systems that underpin and support the unit’s business processes,
keeping full and accurate records of all business activities, including the disposal of
records within the privacy and confidentiality obligations of ACT Health recordkeeping
procedures and practises.
ACT Health Staff
ACT Health staff are responsible for:
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making accurate and full records as evidence of their business activities,
identify, classify and capture records including electronic records, into official
recordkeeping system(s), and
protect and dispose of records using approved disposal schedules.
Evaluation
Outcome Measures
 ACT Health compliance with the requirements of the Territory Records Act 2002 and the
Territory Records Office Standards for Records Management.
Method
 Administrative Records Management practices will be subject to audits, conducted by
either ACT Health internal auditors, the Territory Records Office or the ACT Government
Auditor General or others, as endorsed by the Director-General.
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Findings from audits are provided to the Director-General and other relevant Executive
Directors and managers for management and resolution of issues.
Related Legislation, Policies and Standards
Recordkeeping Standards
ACT Health will conform to the Territory Records Act 2002 and the Territory Records Office
Standards for Records Management. This Policy and ACT Health’s Record Keeping Manual
have been developed in conformity with both the Act and the Standards. In cases where
recordkeeping issues arise, which are not covered by the Policy or Procedures, ACT Health
will follow advice from the Territory Records Office and be guided by the Australian Standard
on Records Management: AS ISO 15489.
ACT Health must adhere to the ACT Protective Security Policy Framework for the security
classification and protective control of information assets (in electronic and paper based
formats which match their value, importance and sensitivity. For further reference refer
to 
Legislation
Other Acts influencing the policy may include but are not limited to:
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Dangerous Substances ACT 2004 The purpose of this Act is to protect the health and
safety of people, and to protect property and the environment from damage, from the
hazards associated with dangerous substances.
Electronic Transactions Act 2011 which is “an Act to facilitate the use of electronic
methods in transactions and record-keeping”.
Environmental Protection Act 1997 “an Act to protect and enhance the quality of the
environment”.
Evidence Act 2011 which provides that a court may need to examine records as evidence
of an agency’s decisions and actions and which details requirements relating to the
authenticity of electronic records.
Financial Management Act 1996 which requires “that proper accounts and records are
kept of transactions and affairs of the department in accordance with generally accepted
accounting practice”.
Freedom of Information Act 1989 which provides a right for individuals to seek access to
Territory records including records, about themselves and sets out a number of
exemption provisions.
Medicines, Poisons and Therapeutic Goods Act 2008 which is “an Act to consolidate and
reform the law relating to regulated substances and regulated therapeutic goods, to give
effect to the medicines and poisons standard, and for other purposes”
Information Privacy Act 2014 and Health Records (Privacy and Access) Act 1997 contain
principles governing the collection, safeguarding, access to, use and disclosure of
personal information and personal health information. These Acts protects members of
the public from the misuse of information about themselves and gives people a right to
see records about themselves (subject to any legal requirements on decision makers).
Public Sector Management Act 1994 which establishes “accountability to the
government for the ways in which functions are performed” as a key value of the
ACT Public Service or which sets out the general principles for public administration by
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ACT Government agencies and the general obligations expected of public employees in
carrying out their work.
Radiation Protection Act 2006 which provides for the protection of the health and safety
of people, and for the protection of property and the environment, from the harmful
effects of radiation, and for related purposes.
Territory Records Act 2002.
Work Health and Safety Act 2011 which allows “inspecting or making copies of
employee records that are directly relevant to a suspected contravention” of the Act and
details records to keep regarding health and safety, including representatives, incidents,
activities and entry permits.
Working with Vulnerable People (Background Checking) Act 2011 which outlines
records associated with the requirements for registration of persons engaged in
regulated activity.
Supporting documents
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Whole of Government Thesaurus of Terms Administrative Recordkeeping Manual.
ACT Health Administrative Records Functional Thesaurus
AS ISO 15489.2-2002 (R2013), Record Management.
Australian Standard, Record Management, Guidelines 2002.
ACT Recordkeeping Manual, Recordkeeping Manual (2012)
Territory Record Office Guidelines.
http://www.territoryrecords.act.gov.au/background#relatedLinks
Policies
Clinical Records Management
Relationship to other policies
Other ACT Health policies cover issues related to records management. This policy is not to
be seen as subordinate to them. In the case of any apparent contradiction between policies
the issue is to be referred to the Executive in charge of records management for resolution.
The Executive in charge of records management is responsible for seeing that related
policies are progressively examined to ensure that they reflect the requirements of this
policy without detracting from their own purposes.
This policy is consistent with ACT Health’s Code of Conduct and the ACT Government’s Code
of Ethics.
Definition of Terms
Principal Officer: means the Director-General of an administrative unit or its equivalent.
Record: (a) means information created and kept, or received and kept, as evidence and
information by a person in accordance with a legal obligation or in the course of conducting
business; and (b) includes information in written, electronic or any other form.
Record keeping: means the making and maintaining of complete, accurate and reliable
evidence of business transactions in the form of recorded information.
Doc Number
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Review Date
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Records Management: The field of management responsible for the efficient and systematic
control of the creation, receipt, maintenance, use and disposition of records, including
processes for capturing and maintaining evidence of and information about business
activities and transactions in the form of records (AS ISO 15489).
Records Management Program: A document which 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
Records System: Information system which captures manages and provides access to
records through time (AS ISO 15489).
References
AS ISO 15489.2-2002 (R2013), Record Management
Territory Records Act 2002
Territory Records Office Advice - number 41, 47 and 57
Territory Records Office Guideline – number 1
Review of Policy and Procedures
Disclaimer: This document has been developed by ACT Health, <Business & Infrastructure/ CSSE/Records
Management> 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.
Doc Number
DGD14-022
Issued
Aug 2014
Review Date
Aug 2017
Area Responsible
B&I
Page
6 of 6