Loss of Records

LOSS OF RECORDS

Even with an adequate security protocol in place patient files can be lost either by accident, natural disaster or as a result of theft.

Members should take appropriate measures to remedy any unauthorized access, use, disclosure or disposal of Personal Information as soon as possible after a breach is discovered, including (i) taking steps to recover the Personal Information or to ensure its disposal if it cannot be recovered, (ii) taking steps to ensure that any remaining Personal Information is secured and (iii) notifying anyone affected by the unauthorized access including patients and other health care providers.

If a loss occurs, members are recommended to take the following actions:

  1. Where theft is suspected, immediately telephone the police to report
    the loss.
  2. As soon as possible, personally telephone the patient whose file has been lost and explain what occurred and when.
  3. Follow up this telephone call with a short letter to the patient documenting your communication. Where the loss has been reported to the police, be sure to provide the police file number. If the patient continues under your care it is also a good idea to provide him or her with a set of your standard patient introduction/information forms to be competed and returned to your office.
  4. Contact the President or Membership Coordinator of the BC Association of Homeopaths to advise of the date, circumstances and extent of the loss.
  5. Write letters to any third-parties with an ongoing interest in the patient’s clinical records (for example, Worksafe BC, ICBC, MSP, a private insurer or the patient’s legal counsel) advising them of what is missing and the date of the loss.
  6. If at any time you have sent copies of all or part of the patient file to any of these third parties, your letter should include a request for them to provide you with a copy of what was previously sent to them. This material will assist you in reconstructing the missing file.
  7. As soon as possible, write down or dictate everything you can remember about the patient’s past consultations and treatment using other relevant office records (for example, payment records, sign-in sheets or day sheets) as memory aides.
  8. Draft a short report detailing the circumstances of the loss and steps taken to report the loss and recover the missing materials. Include a review of your security protocol focusing on any procedures to be implemented in the future to avoid similar losses. This report will be valuable in responding to any complaints or investigations (whether by the police or the BC Association of Homeopaths) concerning the loss.