Administration of Hospital Admissions and Discharges Policy

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Administration of Hospital Admissions and Discharges

Policy Statement

The decision to admit a patient to hospital is a clinical decision. Patients may be admitted when at least one of the following criteria apply:

  1. The person’s condition requires clinical management and/or facilities not available in their usual residential environment;

  2. The person requires continuous observation in order to be assessed or diagnosed;

  3. The person requires at least daily assessment of their medication needs;

  4. The person requires a procedure(s) that cannot be performed in a stand-alone facility, such as a doctor’s room, without specialised support facilities and/or expertise available (for example cardiac catheterisation);

  5. The person is aged nine (9) days or less; or

  6. There is a legal requirement for admission, for example under the Mental Health (Treatment and Care) Act 1994.

A patient is considered to be discharged (separated) at the time the hospital ceases to be responsible for the patient’s care and the patient is discharged from hospital accommodation (excludes statistical discharges).

All recording, classifying and counting of public hospital admitted activity in the ACT Local Hospital Network Directorate (LHND) must be based on the Admitted Patient Activity Data Standards endorsed by ACT Health (Attachment A).
Clinical processes for admission and discharge of patients will be undertaken in accordance with each hospital’s policies, operating procedures, protocols or guidelines.


This policy recognises the importance of the clinical decision to admit. The policy also outlines obligations that ensure the decision and associated administrative data are captured in a consistent manner.

Under the National Health Reform Agreement (NHRA), the hospitals within the ACT LHND have an obligation to count, record and classify public hospital activity in a timely, meaningful and consistent manner. This policy and the attached data standards provide a set of detailed clear rules and criteria to support this activity. Implementation of this policy supports the equitable and efficient allocation of resources within ACT Health.

The following principles underpin this policy and its implementation:

  • The patient, carer and family remain the primary concern.

  • The LHND serves the ACT and surrounding community.

  • Data standards should be applied in a consistent manner.

  • Transparency and integrity in data collection and reporting are essential to producing efficient and high quality health services.

  • Policy decisions and rules will be driven by best practice, not software capabilities or system limitations.


Within Scope

The policy applies to all public hospitals within the ACT LHND and contracted hospitals. It applies to both publicly and privately admitted patients within these hospitals.

This policy provides direction for the requirement to capture decisions and related administrative data for admitted patient activity in a consistent manner.
Where an admitted service is contracted out, the contracting body should ensure that the facility provides all the required activity data.
Where hospital specific policies and standard operating procedures related to admitted activity are required, these will align with this policy.
Mental Health Services will have additional complimentary clinical admissions criteria to the admissions criteria within this policy.
Outside of Scope

Decisions to admit and discharge patients are clinical decisions. This policy recognises this and does not seek to provide guidance on how individual clinicians assess, diagnose and treat patients.

Roles & Responsibilities

The responsibility to implement and/or comply with this policy lies with the entire hospital and health care team including:

  • Director-General ACT Health;

  • Deputy Directors-General and Chief Executive Officers (CEOs);

  • All managers including Executive Directors;

  • Clinicians;

  • Data Managers;

  • Data Analysts;

  • Health Information Managers; and

  • Administrative staff.

Deputy Directors-General and Chief Executive Officers have a responsibility to ensure that local procedures and protocols are in place to support this policy.

Clinicians (including medical officers, nurses and allied health professionals) have a particularly important role in ensuring health services compliance with this document. It is the documentation of clinical decision making, and most importantly, how these decisions are communicated and reported, that enables the other team members to perform their duties relating to accurate counting and recording of activity across the ACT LHND.
Governance of Data Standards

The Data Standards Working Group is responsible for the development of data standards within ACT Health. The Information Management Committee will then review and make recommendations for endorsement of the standards to the Director-General for final endorsement.


Outcome Measures

  • Appropriate application of recording, classification and data requirements for the admission, transfer and discharge of patients. Found in the attached standards.


  • Audit, compliance monitoring and assessments of processes by the office of Data Integrity. This will be included as part of the ACT Health data audit plan and reported to the Director General

  • Quality assurance and analysis of activity data by the Funding, Modelling and Analysis Section. This will be conducted annually with reported to the Information Management Committee.

Related Legislation, Policies and Standards


Private Health Insurance (Benefit Requirements) Rules 2011

ACT Health Inter-Hospital Transfer Policy

ACT Activity Based Funding Framework

ACT Health Admitted Patient Activity Data Standards (Attachment A)

Definition of Terms

ACT Local Hospital Network Directorate (LHND)

The ACT Local Hospital Network Directorate is the local hospital network located in the Australian Capital Territory. For the purposes of National Health Reform public hospital funding arrangements, this network is made up of the following public hospitals and service providers:

  • Calvary Hospital

  • Canberra Hospital

  • Clare Holland House

  • Queen Elizabeth II Family Centre


Victorian Hospital Admission Policy, Department of Health Victoria (July 2012).

Admission, Readmission, Discharge and Transfer Policy for WA Health Services, Department of Health Western Australia (July 2012).
Tasmania Counting and Recording Rules for Admitted Activity, Department of Health and Human Services Tasmania.


ACT Health Admitted Patient Activity Data Standards.

Disclaimer: This document has been developed by ACT Health, Performance and Innovation Branch, Data Governance and Standards Unit 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 ACT Health assumes no responsibility whatsoever.

Doc Number

Review Date

Area Responsible


July 2013

July 2015



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