Criterion 4.2.4 Retention of patient health information
Our health service has a system for the retention of patient health information.
► A. Our practice keeps individual patient health information until the patient has reached the age of 25 years or for a minimum of 7 years from the time of our last contact with the patient, whichever is longer (interview).
► B. Our health service has a process for identifying, storing and retrieving inactive patient health information (interview, direct observation).
► C. Our health service has an appropriate method of destroying (eg. shredding) any material containing patient health information before its disposal (interview, direct observation).
Health services need to be aware that there may be specific legislation in their state or territory requiring a minimum period of retention of health records. Such legislation normally recommends that individual patient health records be retained for a minimum of 7 years from the date of last contact, or until the patient has reached the age of 25 years, whichever is the longer. The health service will need to clarify the state or territory legislative requirements relevant to the retention and destruction of health records for patients who are no longer incarcerated in the prison. Such requirements may vary from what is required for community based patient health information.
In the case of patient health information collected for the purpose of providing medical advice or treatment, it may be appropriate to retain this information indefinitely so that it is available, if necessary, to assist with patients’ future diagnosis and treatment.
Additionally, staff need to be aware of the positions taken by medical defence organisations (and any other professional indemnity insurers) with respect to the retention, storage and destruction of patient health information.
The health service must also ensure that inactive patient health records are kept and stored securely – an inactive patient health record is a record of a patient who is no longer detained in a prison.