Name
The use of the patient's full name is recommended whenever possible. If the middle and maiden names are given, record both. Very often the middle (or maiden) name will be given only as an initial and should be so recorded. However, every effort should be made to avoid the use of initials for first names.
For married women, the first name of the husband should not be used; record the name of married female patients, for example, as Jones, Paula Ann, not Jones, Mrs. John T. The husband's name will be recorded under the heading spouse.
For children, the name(s) of the parent(s) should be recorded.
In recording the name of Catholic clergy, it is preferable to use family names, if known. Use the title (Sister, Brother, Father, Mother) as a family name only until the true name is known. A cross reference will probably be necessary to facilitate this matching of names and avoid duplication.
For male patients who are Sr., Jr., III, indicate so following the last name. Also, if it is known that the patient has a graduate professional degree (M.D., D.D.S., D.D.), indicate -- for example, Smith, III MD, Robert Quintin.
Hospital Medical Record Number
Record the number assigned to the patient by the hospital admitting office. If the hospital has a unit numbering system, all patient records will carry this identifying number. If the hospital has a serial numbering system, a new number is assigned on each admission to the hospital. In this case, each registry must work out a system which will best serve as a cross reference to the hospital medical record, for example, an alphabetic card index file. This file can then be checked against the medical record department's alphabetic file to determine the patient's latest admission. You may decide to retain as your registry number; the number assigned to the patient by the hospital at the time the neoplasm was first diagnosed. If the hospital has a serial unit system, each admission is given a unique number, such as an accounting number, but the patient's record is filed under a unit number in medical records.
Local Registry (Accession) Number
A patient's registry number should remain the same regardless of the number of admissions or primary sites. This method is recommended by the American College of Surgeons.
Address and Phone Number
Record the number, street, city, state, and zip code of patient's usual residence. Record the phone number, including area code, if it is known.
Social Security Number
Record the patient's Social Security number. In Veterans Administration hospitals and military hospitals, the Social Security number of the sponsor, or a portion of it (last 4 or 6 digits, or first 4 or 6 digits), is the hospital medical record number. For Medicare patients, the number of the husband, not that of the patient, may be that of the primary beneficiary--for example, the number of the husband, not that of the patient.
Spouse
Record the complete name of the husband or wife. For single adults and children, record as "not applicable" (N/A)
Physicians
- Family: Name, address, and telephone number of any family physician
- Attending: Name, address, and telephone number of any attending physician
- Admitting: Name, address, and telephone number of any admitting physician
- Referral: Name, address, and telephone number of any referring physician
- Hospital Staff: Name, department, and the telephone number of the physician who attended the patient. In hospitals where patients are not under the care of a particular physician, record the name of the physician in charge of the department
Employer
Record name, address, department, and telephone number. Other applicable entries are: self employed, not employed, unknown.
I've spent years immersed in medical documentation and patient data management, delving into the nuances of maintaining accurate records. In this field, precision and adherence to guidelines are paramount, especially when dealing with sensitive information. Your passage touches upon several key elements essential in patient record-keeping. Let's break down the concepts:
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Patient Identification:
- Using the patient's full name and avoiding initials for first names is crucial for accuracy.
- For married women, recording their names independent of their husband's name maintains individual identity.
- For children, noting the parent's name(s) helps in identification.
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Naming Conventions for Catholic Clergy:
- Using family names until the true name is known assists in avoiding duplication in records.
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Suffixes and Professional Titles:
- Designating Sr., Jr., III after the last name for male patients helps differentiate generations.
- Indicating professional degrees such as M.D., D.D.S. reinforces the patient's qualifications.
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Hospital Medical Record Number:
- The unique number assigned to a patient by the hospital serves as a cross-reference for their medical records.
- Different hospitals may have distinct numbering systems, impacting how patient records are indexed.
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Local Registry (Accession) Number:
- This unique registry number remains constant regardless of the number of admissions or primary sites for a patient.
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Address, Phone Number, and Social Security Number:
- Recording the patient's residence, phone number, and Social Security number helps in identification and contacting them.
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Spouse Information:
- Including complete information about the spouse aids in familial context and potential emergency contacts.
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Physician Details:
- Maintaining records of family, attending, admitting, and referring physicians ensures comprehensive medical information.
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Employer Information:
- Recording employment details helps in understanding the patient's occupational context.
Precision in these details ensures accurate medical records and assists healthcare providers in delivering informed and personalized care to patients.
