32 hours ago The report discusses patient identification strategies involving policies and procedures, registration, standardisation, technology, patient and family engagement, and event reporting and response. Crucial to the success of these strategies is the role of senior leadership in supporting initiatives to improve patient identification and to ban what one researcher calls a “culture of low expectations.” >> Go To The Portal
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It is essential that every report in the patient record contain patient identification,which consists of the patient’s name and some other piece of identifying information such as medical record number or date of birth.
Historically, patient identification practices in the US have been fragmented and inconsistent 32. Furthermore, hospitals report that difficulties in accurately matching patients to their health information across health IT systems limit health information exchange 54.
The term “event” includes near-miss events (events that are detected before reaching the patient) as well as events that reach the patient, some of which cause harm. We also asked member organisations and partner PSO s to submit at least 10 events related to patient identification during a six-week call to action (June 18 to July 31, 2015).
The Joint Commission is not alone in advocating for safe practices to ensure correct patient identification. The National Quality Forum lists wrongpatient mistakes as serious reportable events and also considers patient identification as a high-priority area for measuring health information technology (IT) safety.
Patient identifier options include:Name.Assigned identification number (e.g., medical record number)Date of birth.Phone number.Social security number.Address.Photo.
18 HIPAA IdentifiersName.Address (all geographic subdivisions smaller than state, including street address, city county, and zip code)All elements (except years) of dates related to an individual (including birthdate, admission date, discharge date, date of death, and exact age if over 89)Telephone numbers.Fax number.More items...
What is De-Identified Data in Healthcare? The process of de-identification removes all direct identifiers from patient data and allows organizations to share it without the potential of violating HIPAA. Direct identifiers can include a patient's name, address, medical record information, etc.
The following data must be removed for de-identification: Name. Location; all geographic subdivisions smaller than a state, including street address, city, county, precinct, zip code, and their equivalent geocodes.
The glossary of the accreditation manual defines a patient identifier as "Information directly associated with an individual that reliably identifies the individual as the person for whom the service or treatment is intended.
The 18 identifiers that make health information PHI are:Names.Dates, except year.Telephone numbers.Geographic data.FAX numbers.Social Security numbers.Email addresses.Medical record numbers.More items...•
Anonymous – The dataset does not contain any identifiable information and there is no way to link the information back to identifiable information. De-identified – The dataset does not contain any identifiable information, but there is a way to link the information back to identifiable information.
Coded refers to data that no one outside a study team can link to a subject's identity. De-identified refers to data that used to be fully identifiable or coded, until the researcher destroyed all of the identifiers linking the data to study subjects.
De-identified health information, as described in the Privacy Rule, is not PHI, and thus is not protected by the Privacy Rule. PHI may be used and disclosed for research with an individual's written permission in the form of an Authorization.
What is PHI? Protected health information (PHI) is any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment.
Patient identification mistakes can lead to errors in medication administration, incompatible blood transfusion reactions, failure to treat a serious illness or disease, medical treatment for erroneous diagnostic lab results, and procedures being performed on the wrong patient.
Two Patient IdentifiersUse at Least Two Patient Identifiers When Providing Care, Treatment and Services. Wrong-patient errors can occur at virtually any stage of diagnosis and treatment, and can be prevented through the simple practice of using at least two patient identifiers for all patients.
As shown in Figure 1, patient identification occurs throughout the patient’s encounter in the care continuum. ECRI Institute PSO developed a care process map to conceptualise a patient’s movement through any healthcare setting and to show key points when patient identification is necessary.
Incorrect patient identification can occur during multiple procedures and processes, including but not limited to patient registration, electronic data entry and transfer, medication administration, medical and surgical interventions, blood transfusions, diagnostic testing, patient monitoring, and emergency care.
Of the 10,915 events, the analysts eliminated 3,302 reports that were not wrong-patient events and classified the remaining 7,613 events using the patient identification event taxonomy.
For its fifth Deep Dive analysis of a patient safety topic, ECRI Institute PSO selected patient identification. Safe patient care starts with delivering the intended interventions to the right person. Yet, the risk of wrong-patient errors is ever-present for the multitude of patient encounters occurring daily in healthcare settings.
In addition to their potential to cause serious harm, patient identification errors are particularly troublesome for a number of other reasons, including: Most, if not all, wrong-patient errors are preventable.
Many patient identification errors affect at least two people. For example, when a patient receives a medication intended for another patient, both patients— the one who received the wrong medication and the one whose medication was omitted—can be harmed.
Engage patients and their family members in patient identification by explaining the purpose of the organisation’s approach to patient identification and emphasising patients’ and family members’ roles in ensuring correct identification.
Checking at least 2 patient identifiers—usually, name and date of birth, although some providers use a medical record number or another identifier. Checking bar-coded identification information on a patient’s wristband against information on a medication label or the patient’s medical record.
Here are some examples of patient identification errors that occurred in last 5 years: A blood labeling error leads to a deadly transfusion.
Needless to say, it would be upsetting if you were given the wrong medication because a nurse confused you with another patient. Even worse, what if a surgeon performed a procedure on you that was meant for another patient? Patient identification errors are the reason health care providers check your wristband and ask for you to confirm your identity before you receive a test or treatment.
As a patient checked in for chemotherapy treatment, the clerk asked the patient to confirm the information on his wristband. Although the patient confirmed his identification, he did not notice that the information was for a patient with the same name, but a different birth date.
Tragically, the doctor overrode 22 alerts triggered by the electronic record system. Although the pharmacy and/or nurses could have intervened and prevented this deadly medication error, it was ultimately the doctor’s mistake.
In a 2016 STAT article, author John McQuaid explains that the US is far from adopting this solution due to many factors, including privacy and security concerns, political resistance and the widespread use of electronic health records that can’t communicate with each other.
Staff should verify patient identification upon every encounter that requires confirmation, not just at the onset of care delivery that day – even in facilities where nurses and doctors feel they “know” their patients.
The Patient Identification and Matching Initiative, sponsored by the Office of the National Coordinator for Health Information Technology (ONC), focused on identifying incremental steps to help ensure the accuracy of every patient’s identity, and the availability of their information wherever and whenever care is needed.
Office of the National Coordinator for Health Information Technology Patient Identification and Matching Final Report February 7, 2014
Interview participants were chosen to reflect a balance of geography, size, vendor partners, and the type of organization. In addition, the project team held unstructured conversations with other interested industry parties including federal agencies, associations, solution companies, consumer organizations, and individuals who represent much of the continuum of stakeholders, or who have an innovative approach to matching.
While some health systems indicated that they only require three or four very stable data attributes to achieve high quality matching, several with deep experience in patient matching methods noted that they are better served by a larger number of attributes, no matter what those attributes are. For example, Geisinger Health System collects a long list of demographics that are separated into fields: first name, middle name, last name, date of birth, gender, whole social security number, street address, city, state, ZIP, and phone.
environmental scan was performed to assess the current industry capabilities and best practices for patient identification and matching, with a focus on matching records between disparate
Matching records to the correct person becomes increasingly complicated as organizations share records electronically using different systems, and in a mobile society where patients seek care in many healthcare settings. Many healthcare organizations use multiple systems for clinical, administrative, and specialty services, which leads to an increased chance of identity errors when matching patient records. Additionally, many regions experience a high number of individuals who share the exact name and birthdate, leading to the need for additional identifying attributes to be used when matching patient records.
1ONC formally launched the Patient Matching Initiative in September 2013.
ADPH is not endorsing any vendors, but simply providing the requested list. Since September 2016, the following vendors have signed the DSA and established unidirectional or bidirectional interface. Please click here to view the list.
ADPH has been requested by Alabama providers statewide to supply the list of EHR vendors who have signed the Data Sharing Agreement (DSA) for HL7 onboarding. ADPH is not endorsing any vendors, but simply providing the requested list. Since September 2016, the following vendors have signed the DSA and established unidirectional or bidirectional interface. Please click here to view the list.
Usually filed as the first page of the patient record because it is frequently referenced; also called admission/ discharge record.
Record of birth information about the newborn patient and the parents which identifies medical information regarding the pregnancy and birth of the newborn; also called birth certificate.
Documents services received by a patient who has not been admitted to the hospital overnight and includes ancillary services, emergency department services, and outpatient (or ambulatory) surgery; also called hospital ambulatory care record.
Direct the diagnostic and therapeutic patient care activities; also called doctors orders.
Final physician order documented to release a patient from a facility.
Additional diagnoses that describe conditions arising after the beginning of hospital observation and treatment and that modify the course of the patient's illness or the medical care required; they prolong the patient's length of stay by at least one day in 75 percent of the cases.
Chronological description of patient's present condition from time of onset to present; should include location quality, severity, duration of the condition, and associated signs and symptoms.
The patient record is a valuable tool that documents care and treatment of the patient. It is essential that every report in the patient record contain patient identification,which consists of the patient’s name and some other piece of identifying information such as medical record number or date of birth. Every report in the patient record and every screen in an elec- tronic health record (EHR) must include the patient’s name and medical record number. In addition, for paper-based reports that are printed on both sides of a piece of paper, patient identification must be included on both sides. Paper-based documents that contain multiple pages (e.g., computer-generated lab reports) must include patient identification information on all pages.
Facility identification ,including the name of the facility, mailing address, and a telephone number, must also be included on each report in the record so that an individual or health care facility in receipt of copies of the record can contact the facility for clarifi- cation of record content.
The Joint Commission standards require that the patient record contain patient-specific information appropriate to the care, treatment, and services provided. Patient records contain clinical/case infor- mation (e.g., documentation of emergency services provided prior to inpatient admission), demographic information (e.g., patient name, gender, etc.), and other information (e.g., advanced directive). Medicare Conditions of Participation (CoP) require each hospital to establish a medical record service that has administrative responsibility for medical records, and the hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed, properly retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to med- ications and services. All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and dis- cipline) who is responsible for ordering, providing, or evaluating the service furnished. The author of each entry must be identified and must authenticate his or her entry—authentication may include signatures, written initials or computer entry. Medical records must be retained in their original or legally reproduced form for a period of at least 5 years, and the hospital must have a system of coding and indexing medical records to allow for timely re- trieval by diagnosis and procedure to support med- ical care evaluation studies. The hospital must have a procedure for ensuring the confidentiality of patient records. Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released by the hospital only in accordance with federal or state laws, court orders, or subpoenas.
The Joint Commission standards require that a pa-tient consent to treatment and that the record con-tain evidence of consent. The Joint Commissionstates evidence of appropriate informed consent isto be documented in the patient record. The facil-ity’s medical staff and governing board are requiredto develop policies with regard to informed con-sent. In addition, the patient record must contain“evidence of informed consent for procedures andtreatments for which it is required by the policy oninformed consent.” Medicare CoP state that allrecords must contain written patient consent fortreatment and procedures specified by the medicalstaff, or by federal or state law. In addition, patientrecords must include documentation of “properlyexecuted informed consent forms for proceduresand treatments specified by the medical staff, or byfederalor state law if applicable, to require writtenpatient consent.”
Both the paper-based and computer-generated face sheet(or admission/discharge record) (Figures 6-2A and 6-2B) contain patient identification or demo- graphic, financial data, and clinical information (Table 6-2). The face sheet is usually filed as the first page of the patient record because it is frequently ref- erenced. Upon admission to the facility, the attending physician establishes an admitting diagnosis that is entered on the face sheet by the admitting department staff. The admitting diagnosis(or provisional diagno- sis) is the condition or disease for which the patient is seeking treatment. The admitting diagnosis is often not the patient’s final diagnosis,which is the diagno- sis determined after evaluation and documented by the attending physician upon discharge of the patient from the facility.
For a record to be admissible in a court of law accord- ing to Uniform Rules of Evidence, all patient record entries must be dated (month, date, and year, such as mmddyyyy) and timed (e.g., military time, such as 0400). Providers are responsible for documenting entries as soon as possible after the care and treatment of a patient, and predated and postdated entries are
which is an assumed name, during their encounter. The patient might be a movie star or sports figure; receiving health care services under an alias affords privacy (e.g., protection from the press). The name that the patient provides is accepted as the official name, and the true name can be entered in the master patient index as an AKA (also known as). However, the true name is not entered in the patient record or in the billing files. Patients who choose to use an alias should be informed that their insurance company probably will not reimburse the facility for care pro- vided, and the patient will be responsible for pay- ment. In addition, use of an alias can adversely impact continuity of care.