John or Jane Doe patient
If a patient's identity is unknown on admission they are registered as Jane or John Doe. They are given a new chart with a new chart number. During a patients stay or after discharge from hospital, Health records may find a match to previous chart and merge the new and old chart. Medical records will assign a name; typically this is Unknown, Unknown. They will also assign a new birthdate and MRN.
- Use the Chart number that Admitting gave John Doe for his entire stay unless you notice the update of chart number if MR finds it before discharge.
- Data Collectors also enter in the Alias ID collection in the tmp project the alternate MRN, Name or other identifier, eg PHIN.
- If additional info such as Postal Code become available, enter them; else follow the relevant fields "Not applicable" instructions.
- If the real identity becomes available in EPR, update your record to the real info(name, DOB, Chart number and PHIN) (or let Pagasa know if the record was already sent)
- If the real info does not become available, use whatever "fake" info is used in EPR
- See Stolen identities for identity theft charts
PatientFollow Project considerations
When a John Doe is admitted to the hospital, a new chart might be started. If the patient is later identified, the record might adjust to list an old chart number. Now that we assign patients based on PatientFollow Project, this can mean that a patient is initially assigned to one laptop, only to later be assigned to another. We don't receive data that would allow us to catch a change like this, so if you see any indication on a chart that a patient initially arrived unidentified, please watch closely if there was a chart number change. If there was a chart change that would assign the patient to a different collector, coordinate with Pagasa and the second collector to continue/finish collection for that patient with the least wasted effort.
Tina is working on this, see ClientVisitGUID.
Medical Records practices at different hospitals
At HSC the chart number for Doe starts with: 300 then 5 digits. Total 8 digits.
At StB the pt is entered as Unknown, Unknown and is given the next chart number in whatever series is being used.
At GRA the pt is entered as Unknown, Unknown and is given the next chart number in whatever series is being used.