Health Sector (Clinical Records) Retention and Disposal Schedule
Responsible public authority: Health Sector
Queensland Disposal Authority Number (QDAN)
683
Date of approval
14 December 2012
Approved by State Archivist
Janet Prowse
QSA File Reference
QSA12/503
Version
1
Scope of retention and disposal schedule
This schedule covers records created by health sector public authorities that create and manage clinical records. This may include, but is not limited to
Hospital and Health Services and Queensland Health. It is not intended to cover private health facilities.
This Schedule is to be used in conjunction with the General Retention and Disposal Schedule for Administrative Records (GRDS).
References to repealed legislation within this Schedule may be taken to be a reference to current legislation if the context permits.
In the event of an administrative change, or the transfer of a function from one public authority to another, this retention and disposal schedule will continue
to apply to the records covered by the schedule. For further advice on the currency of approved retention and disposal schedules following administrative
change, please contact Agency Services at Queensland State Archives on (07) 3131 7777.
Record Formats
This Schedule applies to records created in all formats, unless otherwise specified in the class description. This includes, but is not limited to, records in
business systems, maps, plans, photographs, motion picture and records created using web 2.0 media.
Queensland State Archives
Department of Science, Information Technology, Innovation and the Arts
Queensland State Archives
Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
Authority
Authorisation for the disposal of public records is given under s.26 of the Public Records Act 2002 (the Act).
No further authorisation is required from the State Archivist for records disposed of under this schedule. However, the disposal of all public records must be
endorsed by the public authority’s Chief Executive Officer, or authorised delegate, in accordance with Information Standard 31: Retention and Disposal of
Public Records, and recorded in the public authority’s disposal log.
Public records that are not covered by an approved retention and disposal schedule cannot be disposed of by a public authority.
Disposal of public records not covered by an approved retention and disposal schedule is a contravention of s.13 of the Act.
Revocation of previously issued disposal authorities
Any previously issued disposal authority which covers disposal classes described in this retention and disposal schedule is revoked. Health sector public
authorities should take measures to withdraw revoked disposal authorities from circulation. This includes, but is not limited to:

QDAN 546 v.3 issued in August 2007 to Queensland Health
Public records sentenced under revoked retention and disposal schedules should be re-sentenced prior to disposal.
For further advice on the currency of approved retention and disposal schedules, please contact Agency Services at Queensland State Archives on
(07) 3131 7777.
Retention of records
All of the retention periods in this schedule are the minimum period for which the sentenced records must be maintained. Public records cannot be
disposed of prior to the expiration of the appropriate retention period. However, there is no requirement for public records to be destroyed at the expiration
of a minimum retention period.
Public records must be retained for longer if:
i.
ii.
iii.
iv.
v.
the public record is or may be needed in evidence in a judicial proceeding, including any reasonably possible judicial proceeding
the public records may be obtained by a party to litigation under the relevant Rules of Court, whether or not the State is a party to that litigation
the public record must be retained pursuant to the Evidence Act 1977
there is a current disposal freeze in relation to the public record, or
there is any other law or policy requiring that the public record be retained.
This list is not exhaustive.
Public records which deal with the financial, legal or proprietorial rights of the State of Queensland or a State related Body or Agency regarding another
legal entity and any public record which relates to the financial, legal or proprietorial rights of a party other than the State are potentially within the category
of public records to which particular care should be given prior to disposal.
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Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
Records which are subject to a Right to Information application are to be retained for the period specified in section 9 – INFORMATION MANAGEMENT of
the General Retention and Disposal Schedule for Administrative Records in addition to their required retention period according to an approved retention
and disposal schedule. The two periods run concurrently, and may result in a longer required retention period overall. This is in order to cover all appeal
and review processes. Even though the records subject to an application may be ready for disposal according to an approved retention and disposal
schedule at the time of the Right to Information application, the additional Right to Information retention requirements must still be applied. See section 9 –
INFORMATION MANAGEMENT of the General Retention and Disposal Schedule for Administrative Records for records of Right to Information
applications.
The disposal of public records should be documented in accordance with the requirements of Information Standard 31: Retention and Disposal of Public
Records.
For further advice on the retention and disposal of public records under an approved retention and disposal schedule, please refer to the Queensland State
Archives website or contact Agency Services at Queensland State Archives on (07) 3131 7777.
Records created before 1950
Records described in683 v.1 that were created before 1950 should be referred to Queensland State Archives for further appraisal before any disposal
action is taken by the public authority. For further advice please refer to the Public Records Brief: Management of Public Records Created Before 1950
which is available from the Queensland State Archives’ website.
Transfer of public records to Queensland State Archives
Records covered by a class with the disposal action of ‘Retain permanently’ should be transferred to Queensland State Archives with the approval of the
State Archivist. Records covered by a class with the disposal action of 'Retain permanently by health sector public authorities’ are not eligible for transfer to
Queensland State Archives unless re-appraised and assigned a disposal action of 'Retain permanently'.
Agencies are required to submit a transfer proposal containing details of the records under consideration for transfer. Queensland State Archives will
assess the transfer proposal before formal approval to transfer is issued. Please refer to the Guideline on Transferring Public Records to Queensland State
Archives available from the Queensland State Archives’ website. The State Archivist reserves the right to revise any previous decisions made with regard
to the appraisal and transfer of records. Contact Agency Services at Queensland State Archives on (07) 3131 7777 for further details.
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Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
TABLE OF CONTENTS
1. CLINICAL RECORDS – GENERAL ......................................................................................................................................................... 6
Clinical Records – Adults .......................................................................................................................................................................................... 6
Clinical Records – Minors ......................................................................................................................................................................................... 6
Clinical Records – Deceased Minors......................................................................................................................................................................... 6
2. CLINICAL RECORDS – EXCEPTIONS ................................................................................................................................................... 7
Clinical Research Records – Adults .......................................................................................................................................................................... 8
Clinical Research Records – Minors ......................................................................................................................................................................... 8
Routine clinical worksheets ....................................................................................................................................................................................... 8
Handover worksheets ............................................................................................................................................................................................... 9
Films and other visual material.................................................................................................................................................................................. 9
Mental Health Facility Clinical Records – Persons of Special Notification (PSN) ....................................................................................................... 9
Mental Health Facility Clinical Records – Mental Health Act 1974 – Forensic Patients ........................................................................................... 10
Notifiable Disease Treatment Records .................................................................................................................................................................... 10
Obstetric Records without evidence of Artificial Insemination/In-vitro Fertilisation (IVF) .......................................................................................... 11
Obstetric Records with evidence of Artificial Insemination/In-vitro Fertilisation (IVF) ............................................................................................... 11
Artificial Insemination/In-vitro Fertilisation (IVF) Donor Records .............................................................................................................................. 12
Unborn Child at Risk Notifications ........................................................................................................................................................................... 12
Organ and Tissue Donors Records ......................................................................................................................................................................... 12
Pharmacy/Medication Records ............................................................................................................................................................................... 12
3. REGISTERS AND INDICES ................................................................................................................................................................... 13
Admission and Discharge Registers........................................................................................................................................................................ 13
Birth Registers ........................................................................................................................................................................................................ 13
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Death Registers ...................................................................................................................................................................................................... 13
Disease and Operation Indexes .............................................................................................................................................................................. 14
Emergency and Outpatient Attendance Registers ................................................................................................................................................... 14
Film and other Visual Material Registers ................................................................................................................................................................. 14
Master Patient Indexes (MPI)/Patient Master Indexes (PMI)/Master Patient Registers (MPR) ................................................................................ 14
Mental Health Registers .......................................................................................................................................................................................... 15
Number Registers/Patient Number Registers/Client Number Registers .................................................................................................................. 15
Operation/Theatre Registers ................................................................................................................................................................................... 15
Short Term Registers .............................................................................................................................................................................................. 16
Vaccination Register ............................................................................................................................................................................................... 16
Vaccination Register Forms .................................................................................................................................................................................... 16
GLOSSARY ................................................................................................................................................................................................ 17
SUBJECT INDEX ........................................................................................................................................................................................ 18
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Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
1. CLINICAL RECORDS – GENERAL
Records displaying evidence of clinical care to an individual or groups of patients/clients.
See Section 2 for specific clinical records having different retention periods or special requirements other than those covered by this Section.
Reference
1.1
Description of records
CLINICAL RECORDS – ADULTS
Status
Temporary
Retain for 10 years after
last patient/client service
provision or medico-legal
action.
Temporary
Retain for:
Records displaying evidence of clinical care to an individual or groups of adult
patients/clients.
Excludes clinical record exceptions covered by Section 2 of this Schedule.
1.2
CLINICAL RECORDS – MINORS
Records displaying evidence of clinical care to an individual patient/client who is a
minor.
10 years from patient/client
attaining 18 years of age;
Includes dental records displaying clinical care provided to children by the Child and
Adolescent Oral Health Services (formally known as School Dental Services).
AND
10 years after last
patient/client service
provision or medico-legal
action.
Excludes clinical record exceptions covered by Section 2 of this Schedule.
See also 1.3 for clinical records of deceased minors and 2.6 for obstetric records.
1.3
Disposal action
CLINICAL RECORDS – DECEASED MINORS
Temporary
Retain for:
Records displaying evidence of clinical care to an individual patient/client who was a
minor and who has deceased prior to attaining adulthood.
10 years from date of
patient’s/client’s death;
Includes clinical records related to neonatal deaths where there is no evidence of
artificial insemination or in-vitro fertilisation procedures.
AND
See 2.6.2 for records of neonatal deaths where there is evidence of artificial
insemination or in-vitro fertilisation procedures.
10 years after last medicolegal action.
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Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
2. CLINICAL RECORDS – EXCEPTIONS
Specific clinical records having different retention periods or other special requirements other than those detailed in Section 1 of this Schedule.
Reference
2.1
Description of records
Status
Disposal action
CLINICAL RESEARCH RECORDS
Clinical records relating to clinical research (including trials) where:
 the Health Department has been the investigator and/or the institution in accordance with the Therapeutic Goods Administration’s
(TGA) Note for Guidance on Good Clinical Practice (CPMP/ICH/135/95); and
 the sponsor has notified the Health Department in writing that the records are no longer required in accordance with Section 5.5.12
of the Therapeutic Goods Administration’s (TGA) Note for Guidance on Good Clinical Practice (CPMP/ICH/135/95).
Records comprise the clinical records created before, during and after a clinical trial in accordance with Section 8 of the Therapeutic
Goods Administration’s (TGA) Note for Guidance on Good Clinical Practice (CPMP/ICH/135/95), including (but not limited to):
 Patient/client or subject’s consent for participation
 Patient/client or subject’s authorisation for use of his/her information from the study
 Laboratory results
 Other diagnostics or investigative reports
 Clinical questionnaires
 Clinical surveys.
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Reference
2.1.1
Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
Description of records
Clinical Research Records – Adults
Status
Temporary
Clinical research records where the patients/clients or subjects were adults.
Disposal action
Retain for:
15 years from
completion of clinical
research/trial;
AND
10 years after last
patient/client service
provision or medicolegal action.
2.1.2
Clinical Research Records – Minors
Temporary
Clinical research records where the patients/clients or subjects were minors.
Retain for:
15 years from
patient/client attaining
18 years of age;
AND
10 years after last
patient/client service
provision or medicolegal action.
2.2
CLINICAL WORKSHEETS
2.2.1
Routine clinical worksheets
Routine clinical worksheets (e.g. daily fluid balance sheets) where the outcome/results
are transferred to the patient’s/client’s clinical record.
Temporary
Retain until the
accuracy of the
outcome/results,
transferred to the
patient’s/client’s
clinical record, have
been verified.
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Reference
2.2.2
Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
Description of records
Handover worksheets
Status
Disposal action
Temporary
Retain until the end of
the corresponding
shift.
Clinical worksheets and notes made to facilitate the handover and change of shifts.
2.3
DIAGNOSTIC IMAGING AND OTHER AUDIO VISUAL MATERIAL
Includes diagnostic radiology, nuclear medicine, ultra-sound, computerised tomography, magnetic resonance imaging, and videos.
2.3.1
Films and other visual material
Temporary
Retain for 5 years
after image or
recording was made.
Temporary
Retain for:
Radiographic films or diagnostically equivalent images/material.
2.4
MENTAL HEALTH RECORDS
See 1.1 to 1.3 for mental health clinical records not described in 2.4.1 and 2.4.2 below.
See 3.9 for Mental Health Registers.
2.4.1
Mental Health Facility Clinical Records – Persons of Special Notification (PSN)
Records displaying evidence of clinical care at a mental health facility of an individual
patient/client with “Persons of Special Notification (PSN)” status.
85 years from
patient’s/client’s date
of birth;
AND
10 years after last
patient/client service
provision or medicolegal action.
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Reference
2.4.2
Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
Description of records
Status
Mental Health Facility Clinical Records – Mental Health Act 1974 – Forensic
Patients
Temporary
NOTIFIABLE DISEASE TREATMENT RECORDS
AND
10 years after last
patient/client service
provision or medicolegal action.
Temporary
Records displaying evidence of clinical care for the treatment of an individual patient/client
for any of the following notifiable diseases:
 Hepatitis B
 Hepatitis C
 HIV
 Leprosy
 Q Fever
 Severe Acute Respiratory Syndrome (SARS)
 Syphilis
 Tuberculosis
2.6
Retain for:
85 years from
patient’s/client’s date
of birth;
Records displaying evidence of clinical care at a mental health facility of an individual
patient/client with a forensic order made in accordance with the repealed Mental Health
Act 1974 where the forensic order expired prior to the implementation of the Mental
Health Act 2000.
2.5
Disposal action
Retain for:
85 years from
patient’s/client’s date
of birth;
AND
10 years after last
patient/client service
provision or medicolegal action.
OBSTETRIC RECORDS
Clinical records related to obstetrics including records related to artificial insemination and in-vitro fertilisation.
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Reference
2.6.1
Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
Description of records
Status
Obstetric Records without evidence of Artificial Insemination/In-vitro Fertilisation
(IVF)
Temporary
Disposal action
Retain for:
10 years from the
child attaining 18
years of age;
Records displaying evidence of obstetric care to an individual patient/client where there is
no evidence of artificial insemination or in-vitro fertilisation (IVF) procedures.
Records may include but are not limted to:
 clinical records of the mother
 clinical records of the child.
See 2.6.2 for obstetric records where there is evidence of artificial insemination or in-vitro
fertilisation (IVF) procedures.
AND
10 years after last
patient/client service
provision or medicolegal action.
See 1.3 for clinical records of neonatal (28 days or less) deaths where there is no
evidence of artificial insemination or in-vitro fertilisation (IVF) procedures.
2.6.2
Obstetric Records with evidence of Artificial Insemination/In-vitro Fertilisation
(IVF)
Permanent
Retain permanently.
Records displaying evidence of obstetric care to an individual patient/client where there is
evidence of artificial insemination or in-vitro fertilisation (IVF) procedures.
Records may include but are not limited to:
 clinical records of the mother;
 clinical records of the child;
 clinical records of each other individual or family unit involved in the artificial
insemination or invitro-fertilisation;
 clinical records related to neonatal (28 days or less) deaths where there is evidence
of artificial insemination or in-vitro fertilisation (IVF) procedures;
 records relating to consent to treatment, use of semen, ova or embryos and
withdrawal of consent.
See 2.6.1 for obstetric records where there is no evidence of artificial insemination or invitro fertilisation (IVF) procedures.
See 1.3 for clinical records of neonatal (28 days or less) deaths where there is no
evidence of artificial insemination or in-vitro fertilisation (IVF) procedures.
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Reference
2.6.3
Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
Description of records
Artificial Insemination/In-vitro Fertilisation (IVF) Donor Records
Status
Disposal action
Permanent
Retain permanently.
Temporary
Retain for 3 months
after expected
presentation date.
Temporary
Retain for 50 years
from last patient/client
service provision or
medico-legal action.
Temporary
Retain for 10 years
after last patient/client
service provision or
medico-legal action.
Records relating to information about individual donors involved in artificial insemination
or in-vitro fertilisation procedures.
2.6.4
Unborn Child at Risk Notifications
Notifications (such as Unborn Child High Risk Alert Forms) received by health facilities
from the Department of Child Safety that an unborn child may be at risk of harm, where
the patient/client does not present at that facility for delivery.
See 2.6.1 and 2.6.2 for notifications where the patient/client presents for delivery.
2.7
ORGAN AND TISSUE DONORS RECORDS
Records displaying evidence of clinical care to an individual patient/client who has donated
organs/tissues, excluding donations described in Reference 2.6.3
Records may include but are not limited to:
 clinical records of donors who are adults or minors;
 clinical records of donors made prior to and after the organ/tissue donation;
 clinical records of donors where the donation occurs while the patient/client is alive or
after their death;
 written consents to donate organs made by the patient/client, their parent or their
senior available next-of-kin in accordance with s.10, s.11, s.12B and s.22 of the
Transplantation and Anatomy Act 1979.
2.8
PHARMACY/MEDICATION RECORDS
Records relating to medication contained in the clinical records of an individual
patient/client such as drug or medication orders.
Excludes pharmacy records and records of controlled drugs made in accordance with Part
7 of the Health (Drugs and Poisons) Regulation 1996 such as ward drug books, transfer
vouchers, etc.
Excludes records relating to high cost/highly specialised drugs (HSD) such as eligibility
statements, pharmacy registers and usage reports for HSD.
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Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
3. REGISTERS AND INDICES
Patient/Client registers and indices including paper-based and electronic registers. Where a single registers is used to document multiple activities, retain
for the longest minimum retention period for each individual register.
Reference
3.1
Description of records
ADMISSION AND DISCHARGE REGISTERS
Status
Disposal action
Permanent
Retain permanently.
Temporary
Retain for 120 years
after last action.
Temporary
Retain for 10 years
after last action.
Registers comprising details of admission and discharge of patients/clients from health
facilities such as the admission and discharge dates, name, record number, date of birth
or age and sex of the patient/client.
Registers may also include admission and discharge times, address, next of kin,
admitting diagnosis, discharge outcome (e.g. home, transferred, deceased, etc), and
length of stay.
3.2
BIRTH REGISTERS
Registers comprising details of births, which occur at health facilities, such as date and
time of birth, mother’s name, sex of baby and names of medical and nursing staff in
attendance.
Registers may also include mother’s record number, age, address and type of birth,
status of baby at birth (ie live, stillborn).
3.3
DEATH REGISTERS
Registers comprising details of deaths of patients/clients that occur at health facilities
such as date and time of death, name and record number of patient/client.
Register may also include sex, date of birth or age, cause of death and name of medical
officer.
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Reference
3.4
Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
Description of records
DISEASE AND OPERATION INDEXES
Status
Temporary
Retain for 120 years
after last action.
Temporary
Retain for 10 years
after last action.
Temporary
Retain until all the film
and visual materials
described in the
register have been
disposed of in
accordance with
Reference Number
2.3.1 of this
Schedule.
Permanent
Retain permanently.
Register/indexes comprising details of patient’s/client’s disease and operations such as
patients/clients record number, name, sex, age, date of admission, length of stay,
discharge status and destination, responsible Medical Officer or unit, ward, Principal
Diagnosis and other diseases or condition, operation and procedure codes related to that
admission.
3.5
EMERGENCY AND OUTPATIENT ATTENDANCE REGISTERS
Disposal action
Registers comprising details of patient/client attendance at emergency or outpatient
facilities such as date and time of attendance, name, sex, date of birth or age of
patients/clients, attending medical officer.
Registers may also include, record number, address, reason for attendance, and where
available, outcome of follow-up arrangements.
3.6
FILM AND OTHER VISUAL MATERIAL REGISTERS
Registers comprising details including location of diagnostic film and other visual
materials used for tracking purposes and not showing the final disposal of the films.
See General Retention and Disposal Schedule for Administrative Records for the
retention period for control records.
3.7
MASTER PATIENT INDEXES (MPI)/PATIENT MASTER INDEXES (PMI)/MASTER
PATIENT REGISTERS (MPR)
Index/registers comprising details which constitutes the patient master index such as the
name of the health facility, patient’s/client’s number, name, date of birth, gender,
address, and date of patient’s/client’s registration (i.e. the date that record number was
assigned).
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Reference
3.8
Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
Description of records
Status
MENTAL HEALTH REGISTERS
Disposal action
Temporary
Retain for 120 years
after last action.
Temporary
Retain until
administrative use
ceases.
Temporary
Retain for 120 years
after last action.
Registers at health facilities made in accordance with the Mental Health Act 2000 and the
repealed Mental Health Act 1974 such as the register of authorised doctors, register of
patients liable to be detained, restricted patient registers, seclusion registers, etc.
Includes the data sets contained within information systems (such as the Mental Health
Information System (MHAIS)) which comprise the registers.
3.9
NUMBER
REGISTERS/PATIENT
REGISTERS
NUMBER
REGISTERS/CLIENT
NUMBER
Registers comprising details which constitute the Number Register such as unit record
numbers, patient’s/client’s name, date of birth, gender, and date on which the number
was issued.
3.10
OPERATION/THEATRE REGISTERS
Registers comprising details of patient’s/client’s operations performed at health facilities
such as date, serial number of operation, time, patient’s name, sex, age and record
number, diagnosis and operative procedure, name of surgeon, assistant surgeon and
anaesthetists.
Includes register books and data sets contained in electronic registers such as the
Operating Room Management Information System (ORMIS).
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Reference
3.11
Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
Description of records
SHORT TERM REGISTERS
Status
Disposal action
Temporary
Retain until
superseded.
Temporary
Retain for:
Registers with the sole purpose of providing information of temporary, short-value (i.e. to
assisted in the change of shifts) or information already recorded and available in an
acceptable medium (i.e. paper-based or electronic) elsewhere in the public authority (e.g.
admission registers).
Examples include:



3.12
3.13
Ward Registers – daily cumulative listing of inpatient movement within that ward e.g.
admissions, bed transfers, discharges, etc.
Bed Return or Daily Bed Return – daily midnight census for a ward, listing all
inpatients admitted, discharged, transferred, died and those remaining in at midnight.
Daily Inpatient Census – listing of all inpatients within a hospital at the time that the
list was created. List may also include current ward of inpatients, visitor access
permission and a generic statement in regard to each patient’s general condition.
VACCINATION REGISTER
Registers comprising details of vaccinations administered in Queensland since July 1993
such as patient’s/client’s name, date of birth, gender, address, telephone number and
vaccination information.
85 years from
patient’s/client’s date
of birth;
Includes:
AND


10 years after last
patient/client service
provision or medicolegal action.
Vaccination Record Forms between 1 July 1993 and 30 June 1994; and
Data sets contained in electronic registers such as the Vaccination Information and
Vaccination Administration System (VIVAS) since 1 July 1994.
VACCINATION REGISTER FORMS
Vaccination Record Forms documenting the patient’s/client’s details for the vaccination
register where the information has been recorded in the vaccination register.
Temporary
Retain until the
accuracy of data
entry into vaccination
register has been
verified.
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GLOSSARY
For definitions of recordkeeping terms, see the Queensland State Archives’ Glossary of Archival and Recordkeeping Terms available via Queensland State
Archives’ website (www.archives.qld.gov.au).
Clinical
Record
As per the Queensland Health Position Statement on Clinical Records, August 2002, the term Clinical Record will be used to describe
those records that contain data or information relating to individual patient’s/client’s (or groups of patients/clients) created to evidence the
delivery of a clinical service.
Examples of public records considered by Queensland Health to be clinical records Examples of public records not considered by Queensland
include:
Health to be clinical records include:













Admission/discharge forms;
History/referral information;
Examination reports;
Pathology/diagnostic records;
Interpretive reports;
Reports of treatment provided;
Obstetric records;
Drug/medication orders and administrations;
Imaging records, photographs, audiovisual materials;
Signed patient/client consent forms;
Copies of statutory health reports and notifications where the original document
has been forwarded to the governing body;
Examples include records fulfilling obligations under the Births, Deaths and
Marriages Registration Act 2003 and Coroners Act 2003;
Maintenance and sterilisation records of clinical equipment that are linked to one
Unit Record Number (URN) and relates to the provision of a clinical service eg.
Sterilisation Production Record (linked to a patient).










Clinical Ward/Unit/Divisional management records
including statistical reports;
Scientific Services records inclusive of forensic science
and public health science records;
Personnel records of medical, nursing and allied health
staff;
Clinical equipment maintenance records and sterilisation
records that are not linked to a URN and do not relate to
the provision of a clinical service;
Patient billing records;
Patient Travel Subsidy Scheme records and patient
transport records;
Patient complaints;
Clinical Trial records held by a clinical trial
coordinator/data custodian;
Clinical Research records held by clinical research teams;
Mental Health Act Forms
Note: The records not considered clinical records are still public records and must not be disposed of without authorisation from the State Archivist in
accordance with s.13 of the Public Records Act 2002.
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SUBJECT INDEX
Note: References to the QDAN 614 in the index refer to the Queensland Health (Pathology Laboratory Records) Retention and Disposal Schedule (QDAN
614).
admission registers ..................................... 13
adults ...................................................... 8
artificial insemination
minors..................................................... 8
general .......................................................6
clinical records ......................................... 11
trials ........................................................... 7
neonatal .....................................................6
consent to treatment ................................ 11
adults ...................................................... 8
donor records........................................... 12
minors..................................................... 8
artificial insemination / in-vitro fertilisation
(IVF) .................................................. 11
attendance registers (emergency / outpatient)
................................................................ 14
audiovisual clinical records ............................ 9
bed returns (daily) ....................................... 16
birth registers............................................... 13
child safety (unborn child high risk alert forms)
................................................................ 12
children........................................... see minors
worksheets
handover ................................................ 9
routine .................................................... 8
consents
artificial insemination / in-vitro fertilisation
(IVF) ..................................................... 11
clinical research / trials ............................... 7
deaths of minors (clinical records)
diagnostic films ..............................................9
registers ................................................... 14
diagnostic films / images ................................9
diagnostic radiology (images) .........................9
discharge registers ....................................... 13
disease registers / indexes ........................... 14
donor records
organs / tissue donations (Transplantation
and Anatomy Act 1979) ........................ 12
artificial insemination / in-vitro fertilisation
(IVF)...................................................... 12
CPMP/ICH/135/95 (clinical research / trials) .. 7
organs / tissues ........................................ 12
daily bed returns .......................................... 16
drug orders (clinical records) ........................ 12
adults ..................................................... 6
daily fluid balance sheets ............................... 8
minors .................................................... 6
daily inpatient census .................................. 16
embryos (use of in artificial insemination / invitro fertilisation) ....................................... 11
research..................................................... 7
death registers ............................................. 13
client number registers ................................ 15
clinical
records (general)
emergency attendance registers .................. 14
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Queensland State Archives
films (diagnostic) ........................................... 9
registers ................................................... 14
Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
donor records ........................................... 12
IVF (in-vitro fertilisation)
Mental Health Information System (MHAIS) . 15
minors (clinical records)
forensic orders (Mental Health Act 1974)..... 10
clinical records ......................................... 11
clinical research / trials ...............................8
handover worksheets / notes ......................... 9
consent to treatment ................................ 11
deceased minors ........................................6
Health (Drugs and Poisons) Regulation 1996
donor records ........................................... 12
general .......................................................6
transfer vouchers / ward drug books ........ 12
leprosy (treatment records) .......................... 10
organ / tissue donors ................................ 12
hepatitis B (treatment records) .................... 10
magnetic resonance imaging ......................... 9
neonatal deaths (clinical records) ...................6
hepatitis C (treatment records) .................... 10
master patient indexes (MPI) ....................... 14
highly specialised drugs (HSD) .................... 12
master patient registers (MPR) .................... 14
artificial insemination / invitro-fertilisation
(IVF)...................................................... 11
HIV (treatment records) ............................... 10
medication orders (clinical records).............. 12
HSD (highly specialised drugs).................... 12
mental health (clinical records)
images (diagnostic) ....................................... 9
adults ......................................................... 6
indexes
forensic orders ......................................... 10
diseases .................................................. 14
minors ........................................................ 6
master patient .......................................... 14
Persons of Special Notification (PSN) ........ 9
operations ................................................ 14
registers ................................................... 15
patient master .......................................... 14
Mental Health Act 1974
inpatient census (daily) ................................ 16
forensic orders ......................................... 10
in-vitro fertilisation (IVF)
registers ................................................... 15
clinical records ......................................... 11
consent to treatment ................................ 11
Mental Health Act 2000
registers ................................................... 15
notes (handover) ............................................9
notifiable diseases (treatment records)......... 10
nuclear medicine (diagnostic images) ............9
number registers .......................................... 15
obstetrics
clinical records.......................................... 11
artificial insemination / in-vitro fertilisation
(IVF) .................................................. 11
donor records ........................................... 12
Operating Room Management Information
System (ORMIS) ...................................... 15
operation registers ....................................... 15
operation registers / indexes ........................ 14
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Queensland State Archives
Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
organ donors (clinical records) .................... 12
emergency attendance ............................. 14
outpatient attendance registers ................... 14
films / visual materials .............................. 14
ova (use of in artificial insemination / in-vitro
fertilisation) .............................................. 11
master patient .......................................... 14
pathology
reports within clinical records ..................... 6
patient master indexes (PMI) ....................... 14
patient number registers .............................. 15
Persons of Special Notification (PSN) ........... 9
pharmacy records........................................ 12
Q Fever (treatment records) ........................ 10
questionnaires (clinical research / trials) ........ 7
radiographic films .......................................... 9
radiology (diagnostic images) ........................ 9
registers
admission ................................................ 13
attendance (emergency / outpatient) ........ 14
birth ......................................................... 13
client number ........................................... 15
death........................................................ 13
discharge ................................................. 13
diseases .................................................. 14
mental health ........................................... 15
number ..................................................... 15
operations .......................................... 14, 15
outpatient attendance ............................... 14
patient number ......................................... 15
severe acute respiratory syndrome (SARS)
(treatment records) ................................... 10
shifts (handover worksheets / notes ...............9
short term registers ...................................... 16
surveys (clinical research / trials) ...................7
syphilis (treatment records) .......................... 10
theatre registers ........................................... 15
Therapeutic Goods Administration (TGA)
short term ................................................. 16
Note for Guidance on Good Clinical Practice
(CPMP/ICH/135/95) ................................7
theatre ...................................................... 15
tissue donors (clinical records) ..................... 12
vaccination ............................................... 16
tomography (diagnostic images) ....................9
ward ......................................................... 16
transfer vouchers (Health (Drugs and Poisons)
Regulation 1996) ...................................... 12
reports
clinical research / trials ............................... 7
Transplantation and Anatomy Act 1979
pathology (within clinical records) ............... 6
consents to donate organs / tissues ......... 12
research (clinical)........................................... 7
trials (clinical) .................................................7
adults ......................................................... 8
adults..........................................................8
minors ........................................................ 8
minors ........................................................8
SARS (treatment records) ............................ 10
tuberculosis (treatment records) ................... 10
school dental program (clinical records) ......... 6
ultra-sound (diagnostic images) .....................9
semen (use of in artificial insemination / invitro fertilisation) ....................................... 11
unborn child high risk alert forms.................. 12
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Queensland State Archives
Vaccination Information and Vaccination
Administration System (VIVAS)................ 16
vaccination register / forms .......................... 16
videos (clinical records) ................................. 9
Health Sector (Clinical Records) Retention and Disposal Schedule : QDAN683 v.1
visual materials (registers) ........................... 14
ward registers .............................................. 16
VIVAS (Vaccination Information and
Vaccination Administration System) ......... 16
worksheets (clinical)
ward drug books (Health (Drugs and Poisons)
Regulation 1996) ...................................... 12
handover ....................................................9
routine ........................................................8
Page 21 of 21