Q: Our computer system crashed and the back-up system failed. I lost my patient records for the past seven months. What should I do?
by Keith Henaman in Documentation on Tuesday, May 15, 2018
A: To minimize any possible sanctions for failing to maintain accurate records as required by law, it can be helpful to take some pre-emptive steps. You didn't mention losing your financial and billing records, but if so, there would be numerous additional issues to address. That is a topic for another day, however, and we will focus on the loss of the clinical records.
The first step is to draft a statement documenting the computer failure, the steps taken to correct the failure, and an explanation of any actions you've taken to reduce the loss of data. It can be helpful to include a letter from a computer specialist reaffirming the technological steps you took to prevent a reoccurrence.
Next, reconstruct summaries of each patient's care and place them in the charts. The summary should include a statement that the original records were lost as a result of a computer malfunction and that the summary contained within the chart was merely a re-creation of your best recollection of a particular patient's condition based upon the financial and billing records.
The summary should not look like an actual reproduction of the record. It should be dated and signed when the summary was created, not when the SOAP notes were originally taken. In addition, these summaries must be clearly labeled as reconstructions of the notes lost due to a computer failure and not intended to be the equivalent of the original.
Depending on your practice preference, you may wish to contact your active patients over a set timeframe (e.g., six months) and give them the prerogative to come into your office for a re-evaluation. There should be no charge for this service because it was caused by something that happened to your office records. You may wish to consult your attorney or your state association for advice on the best way to approach this.
Finally, for the future, consider developing a secondary back-up system so that a similar computer system crash and back-up system failure would not be as disastrous.