Retention, destruction and disposal of patient health records

Retention periods of health records                                           

Health records are retained primarily for the purposes of ongoing patient care or treatment. Where relevant, records should be kept until such time as there is little or no risk of litigation arising from the care of a patient. This will depend upon the statutory limitation period within the relevant jurisdiction and any applicable legislation governing medical records, which vary between jurisdictions.

In Australia, three jurisdictions – the ACT, NSW and Victoria – have legislation prescribing the minimum period of time for which medical records should be kept:

• Adults – 7 years from the date of the last contact
• Children – until the child reaches 25 years of age.

In Aotearoa New Zealand, the minimum retention period for health information is 10 years, beginning on the day after the date shown in the health information when services were last provided to that individual. Please refer to the Health (Retention of Health Information) Regulations 1996.

Refer to the table below for the jurisdictional retention periods of patient health records. 

Psychiatrists should be aware that:

• The death of a patient does not alter that their record must be retained for the legislated period of time.
• Courts have the discretion to extend the minimum retention periods in certain circumstances.
• In certain circumstances consideration should be given to an extended period of retention of patient health records.
• Whenever there has been a patient complaint, an adverse outcome, medico-legal proceedings, forensic services involvement or other purpose (e.g. Medicare claim) have been foreshadowed, the medical records should be kept indefinitely. If relevant, the health records of a patient who has a current claim for damages or is subject to a guardianship or other court or tribunal order should also be kept indefinitely, or until seven years after the patient’s death.

Destruction of health records

When health records are no longer required steps must be taken to permanently destroy them in a manner that preserves the confidentiality of patients. This entails taking reasonable steps to destroy or permanently de-identify the personal health information of patients. Some jurisdictions – ACT, NSW and Victoria – require health care professionals to keep a register identifying the:

• name of the individual to whom the health information related
• period of time over which the health record extends
• date on which the record was deleted for disposed.

If a commercial company is used to dispose of health records, the company should provide certification to confirm confidential destruction. Copies of any certificates of destruction should be retained.

In all cases, a psychiatrist should contact their MDO before destroying any medical records. This will ensure compliance with any individual requirement that may exist as part of professional indemnity.

Disposal of health records when closing a practice

Refer to: RANZCP Management of patient health records when closing a private psychiatric practice.

Practice policies on retention and destruction of health records

Psychiatric practices should consider having a policy on document retention and destruction that encompasses:

• identification of documents that should be destroyed from time to time
• review of documents to ensure they are not relevant for any existing or possible future dispute
• destruction of the document is made at the appropriate management level
• notification of all practice staff of the policy and ensuring the policy is enforced
• search and retrieval processes.

Contact

For enquiries about this page, contact policy@ranzcp.org.

Disclaimer

This information is intended to provide general guide to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances or information or material that may have become subsequently available.