Health Information Management

What to do when a physician leaves and forgets records

HIM-HIPAA Insider, August 24, 2004

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Doctors often move without telling the HIM department. Sometimes, they fail to inform the medical staff.

Rather than taking incomplete records to the medical record committee to review and sign off, consider creating a form to use in the following three instances.

  1. Physician moves out of town. HIM staff should contact the physician before he leaves town. If unsuccessful, the next step is to reach them by phone or through mail at either their new office or home to request a dictation for the physician to sign records.

  2. Physician dies. Close the records after checking with the partners of the deceased physician, or others involved in the case, to see whether they were familiar enough with the case to feel comfortable signing off on the charts. The signature should indicate that Dr. Jones is signing for Dr. Smith who is unavailable. This can also be used if an out-of-town physician can't be tracked down.

  3. A record was lost for a long time, found, and discovered to be incomplete. If so much time has passed that the MD is unable to make reconstruction notes, ask the doctor to dictate something with appropriate caveats. For example, ask the physician to say something such as, "Due to the length of time that has passed, I can not recall the details." If the MD can't remember anything, file it incomplete.

Keep the form short and simple. Describe in brief why the records are being filed incomplete. Be sure to inform medical staff on which records are incomplete. The HIM director should be the only person with the authority to use the form and this policy should be added to the Medical Staff Bylaws.

This excerpt is adapted from the book Mastering Records Completion 2: More Strategies from Medical Records Briefing.

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