Family Nursing & Home Care Missing Record Procedure

Approved by: P Massey Date Approved: 07.01.11

Review Date: 07.01.14

1. Policy Statement

Missing records are a serious risk to clients and the Association and it is therefore vital

that the tracing and tracking procedure, listed below undertaken at all times.

2. Policy Scope

This procedure applies to all Family Nursing and Home Care Staff.

3. The Process

Within Family Nursing and Home Care, in the event of health/corporate records being lost

from FNHC premises and/or other locations, the following procedure must be followed:

1. As soon as the records are discovered to be lost, ideally within 24 hours, the

relevant clinician/staff member must check the following :

o Work areas

o Archiving Department o Patients Home if applicable o With Colleagues

o Hospital Liaison Sister if applicable o

Other agencies involved if applicable

2. An attempt must be made to trace back to where and when the records were

last available.

3. If the record(s) still remain missing then the person who discovered the records

were missing, must complete a Missing Record Form (Appendix 1). It may be

necessary at this point to commence a temporary record, however if they are

missing for longer than 1 week a full record should be completed.

4. The Missing Record Form must be sent to the Information Governance Team, who

will complete the Missing Record Log (Appendix 2).

5. A copy of the Missing Record Form will also be placed into the archives, this will

then alert the Information Governance Team if missing records are returned.

6. The Information Governance Team will also make further enquires with other

agencies, hospital medical records department as appropriate, other staff members

in order to locate the records.

7. Where exhaustive searches fail to find the record(s) it will be considered lost. The

Information Governance Officer will inform the Caldicott Guardian who will sign

off the record as lost and a new record will be implemented, if the missing records

contain patient/client or staff identifiable information. In respect of Corporate

records, these will be required to be signed off as lost by the Divisional Manager

for Governance.

8. If records are not found within 4 weeks, the Caldicott Guardian/Information

Governance Officer must inform the patient and keep them regularly updated.

9. If records are found the Information Governance Team will inform the patient,

necessary staff involved and update the Missing Record Log, returning the record

to them if appropriate.

A Missing Record Process Map (Appendix 3) can be displayed in all areas for ease of

access to the process.

4. Deceased Patients

When a patient receiving our care dies at home or within the hospital, and there are nursing

records in the home, it is the responsibility of the nurse involved to retrieve the records at an

appropriate time, as the records are the property of FNHC. If problems arise in retrieving

these records, please notify the Information Governance Officer within 2 weeks.

5. Sudden Deaths

If a patient suddenly dies at home and the police become involved, often the police will take

the records to investigate. In these circumstances, please notify the Information

Governance Officer, in order for them to retrieve the records for archiving.

6. Responsibilities

Caldicott Guardian

The Caldicott Guardian has overall responsibility to ensure implementation of policies and

procedures relating to information on health.

Information Governance Officer

The Information Governance Officer has overall responsibility for ensuring the processes

detailed within this procedure are implemented, and to ensure that this procedure is updated

and maintained to reflect current working practices.

All Staff

All staff are responsible for the security and the subsequent return to the storage area of

records that they use. Staff who take or send records to another location are personally

responsible for ensuring manual tracer records are used and maintained. All staff are

responsible for reporting missing records.

Reporting

The Information Governance Officer will monitor that the Missing Record Process has

been followed in all missing record incidents and document accordingly. If the process is

not followed the necessary action will be taken up with the appropriate Line Manager.

The Information Governance Officer will maintain an updated list of all records, reported as

missing and forward a monthly report, containing current status to the Divisional Manager for

Governance, who will in turn report to the Chief Executive Officer and Committee.

Document history – Missing Record Procedure

Version Who Changed Date Approved by

1.0 New Policy 07.01.11 P Massey

Version Narrative

Appendix 1

FAMILY NURSING & HOME CARE - MISSING RECORD FORM

Patients HSS No.

Name

D.O.B Department

Date

Required by, Reported by

Purpose and

date required Type of record i.e.

Date last short term,

used CACHR

Point Review Process Comments Sign off

1 Where did you expect the

records to located/held?

State last tracking, date

and user.

2 Where else have you searched/Looked? Please

list all possibilities e.g.

shelf, cabinets, patients

home, other agencies

involved

3 Who else may have taken

them e.g. other colleagues

4 If patient related have they been admitted to a

different agency? Have

you contacted all agencies

involved

5 Information Governance

Officer

6 Missing records log updated

7 Any further action

required? Caldicott Guardian

8 /Divisional Governance Manager Are you happy to sign this

9 off as a lost clinical record? 10 Patient advised of the

missing record

11 Sign and date

Appendix 2

FAMILY NURSING & HOME CARE - MISSING RECORD LOG

Date Identified Patient Name HSS NO. Temporary Staff Member Summary of searches, Date found Process Missing Record set involved investigation, action taken followed

up (Y/N) correctly

Appendix 3

Missing Record Process – Health Records

Sunday, July 25, 2010

Missing Record Identified by

Clinical Staff (within 24 hours)

Check in Archiving Check in patient’s

Check with colleagues

Check with Hospital

home

Liaison Sister

No

Records found

Yes

No action required

Complete a

Complete Missing

temporary record Record Form

Send form to IGO

IGO Team

Complete missing record log

Liaise with Liaise with other

Hospital

agencies involved

Copy of missing

record form to be

put into file in

archives

Records found Records not found

IGO Team

Inform the

Complete missing

Caldicott Guardian New records

signs records off as

necessary staff

record log

completed

missing

Caldicott Guardian/ IGO advised patient

of missing record

Appendix 4