Missing or Lost Patient Medical Record

 POLICY:
** This policy does not apply if the organization's medical 
record documentation is completely Electronic Medical Records 
and back up is performed. 
 
 
A search will be undertaken at any time that a patient 
medical record is missing and cannot be located.  
 
Legal counsel will be contacted regarding this issue, seeking 
advisement regarding any HIPAA violation, such as a breach in 
disclosure of private health care information and requirement 
for notification; as well as any other risks the organization 
may have incurred with the missing or lost patient health 
record etc. 
 
PROCEDURE:
 
A systematic search will be undertaken to locate the record: 
 
1.  All medical record personnel will be requested to search
    for the missing record.
 
2.  The Medical Director and the Clinical Supervisor will be
    notified that a patient chart has been lost; their 
    counsel will be requested regarding possible search 
    parameters.
 
3.  If 48 hours elapse from the time the chart is noted to be 
    missing without it being located, the appropriate 
    authorities will be notified.  
 
4.  The circumstances under which the chart disappeared, the
    protocol in place to prevent such occurrences at the time 
    of the loss, and the corrective active necessary to 
    prevent a future recurrence of this situation will be 
    described organizational minutes.
 
5.  The missing record will be reconstructed:
 
     A.  The patient's card will be annotated with the date 
         the medical record was reported missing.
     B.  A duplicate medical record folder will be made, to 
         be  labeled 'DUPLICATE:  ORIGINAL PATIENT CHART 
         MISSING'.
     C.  The transcriptionist will be requested to provide 
         any available copies of records regarding this 
         patient.
     D.  The patient will be queried regarding other sources
         (physicians, acute facilities, surgery centers)
         which may have medical records to be requested for
         the reconstructed record.
     
6.    When the missing record is located, the reconstructed 
      chart will be carefully reviewed to identify any 
      documents which are not in the original chart.  Such
      documents will be added to the original record with
      all duplicate documents being destroyed.

Approved By Governing Board
PR.8
Control #269.4
GUPTA GASTRO