Procedure. Applies To: UNM Hospitals Responsible Department: HIM / Admitting/ Blood Bank Revised: 8/2015

Transcription

1 Title: Patient Re-identification, Information Correction, and Duplicate Medical Record Number Removal Applies To: UNM Hospitals Responsible Department: HIM / Admitting/ Blood Bank Revised: 8/2015 Procedure Patient Age Group: ( ) N/A (X) All Ages ( ) Newborns ( ) Pediatric ( ) Adult DESCRIPTION/OVERVIEW Patients who have been issued Trauma Alert/Stroke Alert/Doe names or whose armband contains information errors should be re-identified with their actual name as soon as possible. This facilitates patient involvement in their own care, and correct identification by hospital services. Similarly, patients who are found to have more than one Medical Record Number (MRN) must have all information combined under a single MRN to ensure unification of medical records and other clinical information. In the interest of patient safety, changes to name and MRN will be allowed any time after admission. A new type & screen will need to be ordered after the name change to ensure that blood products can be accurately matched to the patient. AREAS OF RESPONSIBILITY Nursing responsible for starting the re-identification process by calling Admitting with the name change. Responsibility extends to re-arm banding the patient once updates have been finalized in the electronic health record. Medical Team responsible for determining the timing of patient information change in both the electronic health record and physical armband. Admitting responsible for obtaining approvals from blood bank and making the necessary changes in the electronic health record. Blood Bank (BB) responsible for ensuring the safety of blood products for those patients who are being re-identified. Health Information Management (HIM) responsible for performing Trauma Alert combines with existing MRN numbers. Outpatient clinics, patient financial services, ancillary service areas, Emergency Department, Cancer Research and Treatment Center, and Out-patient Surgery & Imaging Services (OSIS) responsible for ensuring there is no existing MRN for a patient before creating a new registration. PROCEDURE Re-Identification and Information Edit 1. The decision to change a patient s name or correct an error on the armband is a patient care team decision. A name change should occur as soon as medically appropriate, but must occur before discharge occurs to ensure all medical information is contained under the correct patient Medical Record Number record. 2. Re-identification of a patient can occur when: a. a Trauma Alert/Stroke Alert/Doe patient can identify themselves; b. a Trauma Alert/Stroke Alert/Doe patient can be identified by a family member; c. a Do Not Announce (DNA) patient has been cleared by law enforcement; d. a Trauma Alert patient is hemodynamically stable and should not require the administration of blood products in the next 2-4 hours. e. a patient or family member informs staff of an error in the current information, such as a misspelled name or wrong date of birth. 3. Nursing is responsible for starting the re-identification process by verifying the hemodynamic stability of the patient, discussing with the medical team the possible need for blood product administration in the next 2-4 hours, and calling Admitting to begin the name change process. Page 1 of 7

2 Trauma Alert/Stroke Alert/Doe patients are assessed at the beginning of shift change every 12 hours. 4. Admitting will call the Blood Bank (BB) as a notification of intent to change patient information. 5. If the Trauma Alert/Stroke Alert/Doe MRN is being combined with an existing MRN, Admitting will forward the change of patient information form with the existing MRN to Medical Records, who will perform the combine. After the combine is complete, Admitting is responsible for insuring all patient names and demographic information is correct. 6. For all other changes and edits, Admitting will update the electronic medical record with the changes indicated on the approved change of patient information form. 7. Admitting will alert the primary nurse that the change is complete in the electronic health record. 8. The primary nurse will be responsible for discarding the Trauma Alert or erroneous armband and replacing it with an armband that contains the updated patient information. 9. If necessary a new type & screen must be ordered by the primary nurse as part of the reidentification protocol 10. Admitting will reconcile the Trauma Alert name list on a daily basis. Removal of Duplicate Medical Record Number Duplicate MRN Prevention 1. Prior to creating a new MRN for a patient, staff members must verify that a MRN does not exist for the applicable patient. Please refer to the Registration Decision Tree attached below. If a duplicate medical record has been created, the staff member shall HIM at duplicatemrn@salud.unm.edu to correct the duplicate MRN. The should be sent as a high priority if the medical record needs to be corrected urgently or as a normal priority if it is not urgent. 2. The must include the following elements: a. The incorrect patient name and the correct patient name; b. The patient's correct date of birth; c. The patient's correct social security number; d. The source of the updated information; e. The name and phone extension of the person requesting the correction. Outpatient MRN Combine Process 1. Duplicate MRNs can be identified on the Suspect Duplicate Registration List that is provided to HIM through the IDX system. The MRNs need to be reviewed and corrected by HIM if appropriate. 2. Upon receipt of an request, HIM personnel will determine if the patient is currently an inpatient. If the patient is an inpatient, Doe or Trauma Alert the request will be forwarded to the Admitting Manager and Admitting Supervisor for approval. 3. Locate all electronic and paper chart information for the patient, if applicable. Verify the patient information contained under each number in the chart and in the electronic medical record. This includes: Patient name, date of birth, next of kin, addresses, diagnoses and procedures, social security number, patient s signature, etc. Keep the record number that was originally issued to the patient unless the patient has multiple encounters in the number that was most recently issued. Combine all chart reports into the MRN that will be retained. 4. The HIM staff member will complete a Medical Record Change form if there is an actual chart folder and place it in the front to the chart to identify a change has been made (see attached). 5. HIM will combine the records/encounters by utilizing the Combine Persons function within electronic health record. 6. Upon completion of the combining of the MRNs, HIM will notify Admitting, who will then update demographic information. Inpatient MRN Combine Process 1. If the patient is an inpatient, Doe or Trauma Alert and has two MRNs, Admitting must complete a name change form. 2. HIM places a call to the Blood Bank for approval. Document the person s name from the Blood Bank that approves the MRN change. Page 2 of 7

3 3. When the Blood Bank gives approval for the merge of MRNs, Admitting will notify HIM via e- mail to document the approval to combine records. 4. Once the Inpatient, Doe or Trauma Alert MRNs have been combined and notification from HIM has been received. The primary nurse will all update the patients demographic information and rearmband the patient. 5. Upon request for approval of MRN combines for Inpatient, Doe or Trauma Alert patients, the current type and screen must be expired before the MRN can be combined. This is to ensure that all blood products reserved under the old name can be issued to the patient when needed. Correcting an Incorrectly Merged Medical Record Number 1. If a MRN has been determined to have been incorrectly merged. HIM will determine how to split the documentation and create a new MRN for one of the patients. The information will then be moved by each encounter to the correct the erroneous merge. Patient level data such as problems, medications, and allergies may not move with the documentation. In this case, HIM will contact the patients, place the incorrect information in error for both patients and re-enter the information provided by the patients. Not all information may be captured and may need to be re-entered by providers if and when the patient returns for treatment. 2. HIM will follow their internal notification guideline to contact the patient to inform them of their new MRN. SUMMARY OF CHANGES 1. In Description/Overview ; modified the last sentence to include the steps involved with the blood bank type & screen and deleted the 3 day time period. 2. In Areas of Responsibility, Nurse, deleted the area with the change in patient information form sent to admitting, replaced with a call. Admitting, deleted the change in information form. Blood bank, deleted the process of assisting the unit with re-banding if staffing allows. 3. Under Re-identification Edit Procedure, added to 2.c, when a DNA is cleared by law enforcement. To 2.d. when hemodynamically stable & not needing blood products in the next 2-4 hours Changed #3 to making RN supervisor responsible for the change process each shift by discussing with the medical team and then if appropriate calling admitting to begin the change in name. Added #9. 4. In the Attachments; separated the flowcharts, one for each procedure, MRN Combine and Re-identification Flowchart. Deleted Name Change/Information Edit Request Form. 5. Section Correcting an Incorrectly Merged Medical Record Number added. 6. Replaces document with same name, 10/2012. DOCUMENT APPROVAL & TRACKING Item Contact Date Approval Owner Director, Health Information Management Consultant(s) Sara Koenig, MD, Medical Attending for Pathology & Blood Bank, Melissa Varela-Director Admitting, Jenipher Jones-Tricore Reference Laboratory, Jennifer Ramon-RN Supervisor Committee(s) Clinical Operations PP&G Committee, Nursing Practice PP&G Sub-Committee Y Nursing Officer Sheena Ferguson, Chief Nursing Officer Y Official Approver Ella Watt, Administrator, Financial Services Y Official Signature Date: 9/16/2015 Effective Date 9/16/2015 Origination Date 10/2012 Issue Date Clinical Operations Policy Coordinator 9/18/2015 ar ATTACHMENTS MRN Combine Process Patient Re-identification Flow Chart Registration Decision Tree HIM Patient Identifiers Change Form Page 3 of 7

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7 Name Change/Information Edit Request Note: Type and screens performed under the Trauma Alert name must be expired before any name changes can be requested. (3 days from initial result) Fax form to Admitting at Date: Primary Nurse: Old Information New Information Patient Name: DOB: Encounter #: MRN: Approvals Blood Bank Approval Date Medical Records Approval (MRN Combines only) Date Admitting Representative Date and Time of Cerner Edit RN Witness (for MRN combines) Date Comments Page 7 of 7