Most patients will remember bedside nurses verifying their name and date of birth many times during their hospital stay. Few realize it was registrars who started the patient identification process.
“It is important that registration staff recognize the impact of misidentified registrations,” says Julie Pursley Dooling, MSHI, RHIA, CHDA, FAHIMA.
Duplicate medical records can cause medical mistakes, problems with reimbursement, and even carry legal ramifications. “Patient access plays a critical role in identifying and matching patients to their health record,” says Dooling, director of health information management (HIM) practice excellence with the American Health Information Management Association.
It all starts with collecting accurate patient demographic information. “If a first, last, or middle name is misspelled, which happens because we are all human, there is a possibility of not finding the patient’s previous records in the system,” Dooling explains.
This creates a dangerous problem: a duplicate patient record that is separate from the rest of the patient’s clinical information. To prevent data entry errors, Dooling recommends using a third party augmented data source to confirm names, addresses, and phone numbers.
She also suggests ongoing training for employees on patient identification processes. New hires probably have no idea the demographic information they input affects patient safety. There are several questions a registrar could ask to ensure he or she has identified the correct person:
- Have you ever received care from this facility?
- Is there a certain preferred nickname everyone calls you?
- How do you spell your last name, first name, and middle name?
- What is your legal name on your birth certificate or other legal documents?
- Do I have this punctuation correct in your name?
Patient access uses data in the master patient index to search for patients they are registering. HIM staff are the ones who manage these data. “Identifying gaps in policies and procedures in both areas of practice can solve issues that may lead to errors,” Dooling says.
Part of the issue is registrars do not realize how dangerous a duplicate medical record can be. “Educating users on the dangers of duplicate medical records is a must,” says Ryan Mills, MBA, regional director of access services at Baptist Health Hospital in Lexington, KY.
To really bring this point home, Mills asks registrars to consider a patient with a drug allergy brought to the hospital by ambulance, who arrives unresponsive. “If no one is with the patient to confirm demographics, this could easily result in a duplicate record,” Mills notes.
In this situation, clinicians could end up giving the patient the drug to which he or she is allergic. “You can never trust when a patient states they have not been to your facility,” Mills adds.
Sometimes, people came for a diagnostic test or office visit years ago, and do not recall it. Other times, people do not realize they actually were treated within the health system because they were seen at a different location. To cover all these possibilities, registrars conduct multiple searches for the patient before creating a new medical record. They use this process:
- First, registrars search by the patients’ Social Security number, if the patient agrees to provide it. “This is a unique value that no one else has,” Mills says. There may be two patients named John Smith with the same date of birth, but they will not share the same Social Security number.
- If the initial search returns no results, the second search uses the patient’s first and last name, along with date of birth. “This search will help to capture those individuals who wish not to provide a Social Security number,” Mills explains.
- If there are no results again, registrars perform a final search of the person’s first and last name.
If there are matches, the registrar verifies it is really the same person by gathering some additional demographic information. This search identifies people who are in the system, but are listed under an incorrect name or date of birth. “Only after these three searches is a new medical record to be created,” Mills says.
The department has reduced the number of duplicate records by carefully following these processes. When it does happen, immediate action is taken. “We use the opportunity to re-educate that team member, sharing the associated dangers,” Mills adds.