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Disappearance of Records

The disappearance of the entire medical record is extremely damaging in medical malpractice litigation. The disappearance of the records calls into questions the care rendered the patient and the integrity of the hospital. The hospital must carefully guard its medical records to prevent them from being inadvertently misplaced or stolen by an unscrupulous person. Under no circumstances should the medical record be allowed out the medical records department. If a patient is readmitted to the hospital, the relevant parts of the record (admissions and discharge notes, reports of laboratory tests, and other requested information) should be duplicated, and copies should be sent to the floor to be incorporated in the patient's new medical record. The record of the earlier hospitalization should not be sent to the floor and made the basis of the patient's new records.

Physicians should not be allowed to check out medical records and take them away from the medical records department. The medical records department should provide a comfortable, quiet area for physicians to work on medical records and review charts. Only by enforcing an absolute prohibition on removing records from the medical records area can the medical records administrator prevent the inadvertent loss of a record. If records routinely leave the medical records department, it will be very difficult to guarantee that all the records removed are actually returned to the department. Even if an effective mechanism for checking out the records could be devised, if the physician who checks out the record accidentally loses it, the medical records personnel are in the same position as if the record has been stolen.

 


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