32226
32233
GP/D3-10
Una Hill
Una Hill
C. Bowring
01 July 2011
20 June 2012
01 December 2015
2

This procedure is in place to ensure staff within the Operational Division comply with NHS Fife Procedure Lost & Stolen Health Records GPD3-7 which must be read in conjunction with this document.

Where staff are required to notify others of loss or theft they must do so promptly.      

4. OPERATIONAL PROCEDURE

4.1 Within the Operational Division, in the event of health records being lost or stolen from NHS premises and/or other locations, the following procedure must be followed:

4.1.2 As soon as the records are discovered to be lost, the Line Manager must be informed.  A thorough search must then be instigated of all offices, wards, clinics etc.  The electronic and/or manual tracing systems must be investigated by the Manager and attempts made to trace back to where and when the records were last available. 

4.1.3 Where exhaustive searches fail to find the record(s) it will be considered lost. The Line Manager must complete an Incident Reporting Form IR1 (or use online reporting via Datix) and forward in accordance with instructions.

4.1.4 The Line Manager must report those records deemed lost to the Patient Records & Information Manager, who must then inform the relevant Directorate Manager or Director of Nursing for AHP’s. 

4.1.5 The Patient Records & Information Manager will inform the Director of Public Health of the loss.

4.1.6 The Patient Records & Information Manager must keep a register of all lost or stolen records reported to him/her (see Appendix A GP/D3-10) This register will be regularly collated into a central register by the Data Protection & Caldicott Coordinator, NHS Fife

4.1.7 The Patient Records & Information Manager alerts relevant staff and departments involved in patient care that the records are lost and asked to be vigilant until they are returned.

4.1.8 In order to facilitate patient care meantime, a duplicate health record must be authorised by the relevant Manager.  This must contain all referrals, reports, clinical letters, investigations and results held electronically or available from the patient’s GP, Dentist, and Optometrist etc.

4.2 Where staff consider a health record has been lost outwith NHS Fife premises, they must immediately search the relevant areas.  If the health record is not found, then the procedure to be followed mirrors that of stolen records.

4.3 Where staff witness or consider a health record(s) has been stolen, they must immediately inform their Manager who must inform Patient Records & Information Manager, NHS Fife.

4.3.1 The Patient Records & Information Manager NHS Fife will then inform the relevant Directorate Manager and Director of Public Health who has responsibility for informing the police. 

4.3.2 When informing the police, those responsible will report the following:

  • Type and quantity of records lost or stolen
  • Date and time of loss or theft
  • Where the loss/theft occurred

4.3.3 An Incident Report (IR1) must be completed by the relevant Manager in accordance with NHS Fife’s Incident Management Policy (GP1) detailing whether the record(s) is lost or stolen and forwarded in accordance with instructions.

4.4 FOUND/RECOVERED RECORDS

4.4.1 Staff finding a record must inform their Line Manager in the first instance.

4.4.2 The Line Manager must then inform the Patient Records & Information Manager who will update the register of lost or stolen health records.  Arrangements must then be made by the Patient Records & Information Manager for the records to be merged together and duplicate record shredded.

4.4.3 Relevant staff must then be informed that the health record(s) is no longer lost or stolen. This will include Director of Public Health and Directorate Manager.

4.4.4 Where health records have been reported lost or stolen to the police, the Director of Public Health, NHS Fife must advice police and other persons/authorities of their recovery.

An Equality & Diversity Rapid Impact Assessment has been completed for this procedure.  No negative impacts have been identified.