Information Governance Records Management Guidance Note Number 007: Health Records Policies and Procedures Polices and Procedures

006. Temporary And Duplicate Case records

1. Opening Statement

A temporary case record folder may only be issued on the instruction of a member of the management team when she/he is satisfied that an exhaustive search has been carried out and original case record cannot be found. When duplicate registrations are identified action must be taken to amalgamate both physical case record and computerised system.

2. Procedure for Issuing Temporary Case record Folder

List your local procedure which explains step by step guide i.e. inform clinician, obtain copies of documentation, creating a temporary folder etc.

3. Amalgamation of Documentation

Actions taken when original case record found i.e. shredding of copy documents etc.

4. Tracking of Temporary Case records

Local policy i.e. recording electronically and manually.

5. Amalgamation of Duplicate Registrations/Case records

Local procedure i.e. merge patient index record and contents of both case records physically amalgamated into correct folder etc.

Definition of Terms & Acronyms

Reference (National/local guidelines, standards and legislation)

Links (related policies and guidance) can also include web links if applicable

Policy 009 : Missing Case records