Go to ancillary records.  If you look, you will find that you have many flow charts, aggregate records, notes, nursing reports, care plans, computerized information etc. that you may use. 

When a record is missing I have clients designate an individual responsible to continue looking for the record [not a nurse]  and designate one nurse to collect all of the aggregate data that can be found.

Delores


What am I supposed to do when a medical record is missing and I can't therefore, get the info I need to complete the mds?


HELP!!




Delores L. Galias, RN, RHIT

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