Policy Document Control Page
Title
Title: Missing Records Procedure
Version: 5
Reference Number: CO28
Keywords:
Records, case notes, missing, lost, records log, tracer card, mental health, community, missing record procedure
Supersedes
Supersedes: Version 4
Description of Amendment(s):
•
To include administrative records
•
Duty of Candour included
Originator
Originated By: Carole McCarthy
Designation: Records Manager
Equality Analysis Assessment (EAA) Process
Equality Relevance Assessment Undertaken by: Carole McCarthy
ERA undertaken on: 4 th
January 2016
ERA approved by EIA Work group on:
Where policy deemed relevant to equality-
EIA undertaken by
EIA undertaken on
EIA approved by EIA work group on
CO28 Missing Records Procedure V5 Page 1 of 10

Approval and Ratification
Referred for approval by: Carole McCarthy
Date of Referral: 21 st
January 2016
Approved by: Information Governance Assurance Group
Approval Date: 27 th
January 2016
Date Ratified by Executive Directors : N/A
Executive Director Lead: Medical Director
Circulation
Issue Date: 11 th
February 2016
Circulated by: Performance and Information
Issued to: An e-copy of this procedure is sent to all wards and departments
Procedure to be uploaded to the Trust’s External Website? YES
Review
Review Date: 27 th
January 2018
Responsibility of: Carole McCarthy
Designation: Records Manager
This procedure is to be disseminated to all relevant staff.
This procedure must be posted on the Intranet.
Date Posted: 11 th
February 2016
CO28 Missing Records Procedure V5 Page 2 of 10

INTRODUCTION
Missing/ lost records are a serious risk to the Trust. It is therefore vital that tracing procedures are undertaken at all times.
2. AIM OF PROCEDURE
This procedure:
• Provides a consistent approach to searching and reporting missing paper records
• Allows for advice or guidance to be given in relation to specific cases
• Ensures that a standard approach is adhered to
• Is to be used in conjunction with electronic record tracking guidance
3. SCOPE
This procedure is to be used for missing paper records.
This procedure applies to all clinical and corporate areas of the Trust and should be used when a paper record is unavailable when it is required for use either clinically or for administration purposes. If one record is reported as unavailable then it would be reported as per the Incident Reporting, Management & Investigation Policy
(CO10) as a Grade 4 incident and the Missing Record Procedure as laid out below must be followed. If multiple records are reported as missing at any one time then an Investigation Report (IR) must be completed as per the Incident Reporting,
Management & Investigation Policy (CO10).
4. TRACKING PAPER RECORDS
.
All health / staff record movements must be tracked. If paper health records are tracked electronically such as hospital records in Mental Health Services, then this must be used to record the location of the health record. Individual departments/services will use an auditable tracking log to indicate the location of the health record if it is moved for any reason. All records should be tracked as per the
Records Management Policy (CO20) either electronically or manually. A booking in/out system can be used or tracer cards can be used (for template see Appendix 1)
4.1 Missing Health Paper Records
The Missing Paper Record Procedure has been developed to implement effective tracking systems for records to support the Records Management Policy and support processes to ensure that health records are made available to staff when required. A
CO28 Missing Records Procedure V5 Page 3 of 10

record is kept of all missing health paper records and the reason for non-availability is recorded.
A record is regarded as unavailable if it is in use elsewhere and/ or cannot be retrieved in time for an appointment/contact.
Reasons for records being unavailable may include:
- record needed for another appointment/ admission
- record with another team/ department
- record not tracked
- wrong record /volume sent
- staff unable to retrieve record from storage
Reasons for records unable to be found may include:
- patient has more than one service number
- patient has used an alias
- record lost/missing in transit either externally or internally
- patient unable to locate patient-held record
Record availability should be regularly monitored and measured and appropriate management action taken if the numbers of missing health records increases. The missing record procedure enables this. Missing health records are reported by the incident reporting system in line with the Incident Reporting, Management &
Investigation Policy (CO10).
The procedures and processes should facilitate the availability of the complete record at all times when required.
4.2 Personnel Files
Similarly, the tracer card system can be used for personnel files and if personnel records go missing the Missing Record Procedure should be followed. Record availability should be regularly monitored and measured and appropriate management action taken if the numbers of missing records increases. The missing record procedure enables this. Missing personnel records are reported by the incident reporting system in line with the Incident Reporting, Management &
Investigation Policy (CO10) as a grade 4 incident.
4.3 Administrative Records
Safety and security of records used for administrative reasons which contain person identifiable data (pid) such as diaries, reports, legal documents, complaints, research
& audit, finance, governance and so on is also paramount and the same information governance applies. If an administrative record containing pid goes missing then the missing record procedure is applicable .
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The Missing Record Procedure had been developed to implement effective tracking systems for health, personnel and administrative paper records.
This supports processes to ensure that all records containing personal identifiable data (pid) are made available when required. A record is kept of all missing records and the reason for non-availability is recorded.
A “missing record” is a record that is unavailable within 5 working days of the first attempt to access the record when required for clinical or administrative use such as an out-patient appointment; admission or other service user contact; complaints, legal investigations; subject access requests; incident investigations.
When this occurs the following steps must be undertaken:
1. The member of staff should report this to his/her supervisor/ line manager as soon as possible before the service user is due to attend or record required.
2. The supervisor / line manager should ensure that a thorough search is undertaken, using tracking and service contact history, including initiating a search at the base where the record should be kept.
3. An electronic incident form must also be completed at this stage as per the Incident Reporting, Management and Investigation Policy (CO10).
The incident is graded at 4 or above against code 86 Records Theft or
Loss.
4. On completing the incident form the Duty of Candour now applies to these incidents:
Duty of Candour
The Duty of Candour is a legal duty on hospital, community and mental health trusts to inform and apologise to patients if there have been mistakes in their care that have led to significant harm.
Duty of Candour aims to help patients receive accurate, truthful information from health providers.
All NHS provider bodies registered with the Care Quality Commission
(CQC) have to comply with a new Statutory Duty of Candour
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The Records Managers or Information Governance Manager may instigate the need to complete an Investigation Report (IR) (see
Section 3) depending on the circumstances of the loss e.g. a number of records are identified as missing or a complaint to the
Information Commissioner (ICO) or litigation case may occur. The
IR will include the relevant recommendations and actions and be reviewed by the Divisional Business Units (DBU’s)
5. On receipt of an incident form relating to missing records, the Records
Manager will issue a Missing Record Log (Appendix 2) and procedure to the department and the lead clinician has a duty of candour to inform the service user or carer in the case of health records (if appropriate).
Further advice can be sought from the Information Governance
Manager.
6. The Information Governance Manager grades the incident according to the checklist guidance for Reporting, Managing and Investigating
Information Governance Serious Incidents requiring Investigation
(SIRI). If the incident level is graded a 2 or above then the incident will be reported to the ICO and DH automatically via the IG Incident
Reporting Tool.
If the incidents are reported to the ICO as above then the following should also be notified: Caldicott Guardian, SIRO, Service Director and
Governance Lead.
6. The missing record or volume should be highlighted as missing (adding a comment to this effect on electronic tracking system) and a temporary record should be created, clearly marked as a temporary record, populated with all relevant information available for that service user / member of staff. A temporary record should be set up and tracked on the relevant systems (electronic or manual) or noted that a temporary record has been created.
7. When the original record is located the missing record log should be updated with the details of when/ how the original was located, and the temporary and original record should be merged
8. The supervisor / manager should send a copy of the missing records log to the Records Manager
9. The records management service will be authorised to monitor all departments’ compliance with this procedure and identify any actions to be undertaken
10. The Divisional Business Units (DBU’s) are responsible for implementing any action plans arising from non compliance to the
Records Management Policy in respect of missing or lost records.
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Lost / destroyed records
When a set of records has been missing for 6 months, it is reasonable to assume that the original set of records has been lost.
The missing record log must then be returned to the Records Manager. This is kept with the original incident form.
Missing Hospital Records (Mental Health)
For hospital records (Mental Health) the patient document in the electronic tracking system should be marked as inactive and end dated, leaving an appropriate comment to this effect. The temporary patient document in the electronic tracking system should now be changed to the new working volume
(e.g. Vol 2 HN note). A new master set of records is physically created and comment made in the notes to explain that this is a replacement file. The log of missing records and the electronic tracking system should be updated to reflect this change.
Found Records
When the original records are located the following procedure should be followed:
1. Complete the missing record log to indicate that the original records have been located
2. For health records inform the lead clinician. If the service user / carer had been previously informed that the records were missing the lead clinician will need to inform the service user / carer that the records had been found.
3. Merge the temporary folder with the original set of records
4. For mental health hospital records if the original records are found the temporary patient document on the electronic tracking system should be marked as inactive and end dated as at the date of the physical merge into the case notes that have been found. Remove the comment on these notes on the electronic tracking system
5. Remove the indicator on the electronic tracking system showing that a temporary file or duplicate record is in circulation
6. Update the electronic tracking system with the location of the merged records
7. Inform the Records Manager and the Risk Department.
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Appendix 1
(Use for health or personnel records)
Surname: Forename: Date of birth: NHS or Employee Number:
Destination Date out Destination Date out Taken by (name and contact no.)
Date returned Taken by (name and contact no.)
Date returned
CO28 Missing Records Procedure V5 Page 8 of 10

Completed by
Date Service missing user or staff name
NHS
Number or
Employee
Number
DATE
Last trace and date
Temp record set-up
(Y/N)
DEPT / SERVICE INCIDENT NUMBER:
Reason why not Detail of searches, Service available (i.e. lost, with another service, etc) investigation, action taken user/ employee informed
Yes /No
Date found
/ record merged

Appendix 3
Unable to locate a record
Inform Manager
Records found – No further action required
Thorough search undertaken
After 5 working days records not found
Complete online Incident Form. Record against code 86 – Records theft or loss
(Incident is Graded 4 or above)
Records found
Merge temporary folder with original set of records
Update Missing
Records log & return to Records Manager
Update electronic tracking system (Mental Health hospital health or child health system
)
Governance Manager informs Records Manager
Continue searching on a monthly basis as appropriate (for a minimum period of 6 months)
On receipt of the Incident Form, Records
Manager issues Missing Records Log and procedure. Information Governance Manager undertakes a SIRI. If the incident is a level 2 or above this will then be reported to the ICO and DH automatically via the IG Incident
Reporting Tool and the Caldicott Guardian;
SIRO; Information Governance Manager,
Service Director & Governance Lead.
Records still not found
If a temporary file is made up, record electronically (Mental
Health records/ child health)
Record in the Missing
Record Log & return to
Records Manager
After 6 months if the record has not been found it is now considered ‘lost’