How to Document a Misplaced Medical Record

Missing medical records require hospital and clinical staff to to implement a quick and effective response. In addition, the proper documentation of the missing record -- in conjunction with the creation of a temporary file for future medical record keeping -- remains paramount. Each medical records room must conduct a diligent search in conjunction with prompt communication with patients and/or caregivers to alleviate concerns. Though the use of electronic record keeping mitigates the occurrence of lost medical records, an efficient response remains mandatory.

Things You'll Need

• Temporary record jacket

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Instructions

• 1

  Create a temporary jacket complete with the patient's name and social security number. Place this temporary jacket in the location held by the lost record jacket in the hospital or clinic records room. In addition, file all subsequent medical documents such as consults and medical reports in the temporary file. The contents of this temporary record jacket fall under the guidelines of the Privacy Act of 1974.

• 2

  Complete a lost medical records tracking form. In conjunction with the temporary file, complete a lost records tracking form to store either in the temporary file or with the medical records section supervisor. This tracking document may appear in the form of a small pre-printed card or exist as information recorded on a consult form. In addition, add the patient's name, social security number and the date that the records went missing to the form.

• 3

  Create an electronic note. In the case of lost or missing electronic medical records, create a notation within the medical record keeping database identifying the patient's name, social security number and circumstances surrounding the lost medical file. In addition, create a new database entry for the upload of subsequent medical information.