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