Missing or Lost Patient Medical Record
** 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
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
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
C. The transcriptionist will be requested to provide
any available copies of records regarding this
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