Information Governance Records Management Guidance Note Number 007: Health Records Policies and Procedures Polices and Procedures

009. Missing Case records

1. Opening Statement

Health Records staff are responsible for ensuring that all patients' case records are available for any attendance or admission the patient may have at hospital. In addition to this, case records require to be obtained timeously for a number of administrative processes.

2. Chart Tracking History

Describe steps taken to obtain history, e.g. checking last and previous locations chart tracking system.

3. Procedure for Obtaining Missing Case records

List steps i.e. search shelves, clinic bundles (not tracked), secretaries offices etc.

4. Escalating Problem if Case records Cannot be Found

Local procedure e.g.. passed to Supervisor, Issue of Temporary Folder.

5. Case record Located

Local procedure i.e. original documentation amalgamated, copies shredded, update tracking system.

Definition of Terms & Acronyms

Reference (National/local guidelines, standards and legislation)

Links (related policies and guidance) can also include web links if applicable

POLICY 006: Temporary and Duplicate Case records