Overview
In most instances, patient medical records are electronic and transfer between GPs via an electronic GP2GP file transfer upon successful registration at a practice. PCSE moves physical records directly from one GP to another. We are responsible for the transfer of paper records only, and not the content, and we do not add information to or remove information from a paper record.
Where a patient is not registered with a GP or is deceased, their records go into physical central storage.
If a GP or GP practice notifies us of missing or incomplete medical records, we have established processes which you can find out more about using the tiles below.
Missing records
A medical record can be classed as missing when a record cannot be found or it's not available when required.
A GP practice will contact PCSE to tell us that although the patient is registered, and the GP2GP transfer has been successful, the patient's paper medical record has not been received.
What is the difference between a missing and lost record?
If the missing record has not been located after six months, it is reasonable to assume that the original set of records has been lost.
What happens when a record can’t be found?
We undertake a thorough search in our secure storage site(s), and we may request GP Practices to also search for the record. If after 5 working days, the record has not been found, we report this to our Information Governance team, who update PCSE Online to show the record as missing.
Why do you keep asking our practice to look for missing records?
If a review of the tracking history of the missing record shows a patient was registered with a GP practice, we will ask you to look for the record, as part of our thorough search.
How do I know if a record is missing?
The missing record will be marked as ‘missing’ on PCSE’s systems as well as a practice's clinical system.
How can I notify you that a patient's medical record is missing?
A GP or GP practice can submit an enquiry via Contact us page, choosing Medical Record Movement, then New Medical Record movement enquiry to tell us that a patient's medical record is missing.
Can a missing record be replaced?
A missing record must be reconstituted, and populated as far as possible with all the relevant information and clearly marked as a ‘reconstituted record’. If applicable, tracking systems should be updated to note the record has been reconstituted and on what date.
What happens when the original record is found?
The original record and the reconstituted record should be merged together. If applicable, tracking systems should be updated to state the original record were located, merged with the reconstituted record and the location of the merged records. The Information Governance team should be updated with details of when and how the record was found.
Incomplete Records
An incomplete medical record means there is information missing from certain periods.
On occasion, a GP practice will contact PCSE stating that the record is incomplete and want to find the missing information.
When a GP practice contacts us to say a medical record is incomplete, we will:
- check with central storage that all records that have been received have been sent out to the current GP practice
- contact the last known data controller for the missing portion to forward on to the current GP practice
How can I notify you that a patient's medical record is incomplete?
A GP or GP practice can submit an enquiry via Contact us page, choosing Medical Record Movement, then New Medical Record movement enquiry to tell us that a patient's medical record is incomplete.
What happens if the missing portion of the record is found in central storage?
Any records found in central storage will be forwarded to the registered GP Practice.
What happens if the missing portion of the records is not found in central storage?
PCSE will contact that last known GP Practice for the missing notes, and if found, these will be forwarded to the current practice.
If the last known practice is closed, we will signpost the current practice to the relevant Commissioner to ask them to assist in locating the missing portion of the notes.
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