Patient Identification

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Download the PDF guide to access the checklist of recommended practices for self assessment and a supporting worksheet to identify action steps to achieve those recommended practices.

The Patient Identification SAFER Guide identifies recommended safety practices associated with the reliable identification of patients in the EHR. Accurate patient identification ensures that the information presented by and entered into the EHR is associated with the correct person. Processes related to patient identification are complex and require careful planning and attention to avoid errors. In the EHR-enabled healthcare environment, providers rely on technology to help support and manage these complex identification processes. Technology configurations alone cannot ensure accurate patient identification.1 Staff also must be supported with adequate training and reliable procedures.

This self-assessment can help identify and evaluate where breakdowns related to patient identification occur in the healthcare setting. The self-assessment focuses on processes within organizations related to the creation of new patient records, patient registration, retrieval of information on previously registered patients, and other types of patient identification activities. The recommended practices can help prevent or detect and mitigate problems caused by duplicate records, patient mix-ups, and “comingled” (or "overlay") records.2-11

This guide is meant to support and enable patient matching technology and capabilities, focusing on best practices for improving data accuracy, which is the first necessary step to ensuring accurate patient matching. However, patient matching between organizations is not the focus of this guide. The recommended practices in this Patient Identification SAFER Guide provide support for many, varied patient matching technologies, as well as alternatives and best practices on specific patient attributes for patient matching, which are likely to change over time.

Completing the self-assessment in the Patient Identification SAFER Guide requires the engagement of people both within and outside the organization (such as EHR technology developers). Because this guide is designed to help organizations prioritize EHR-related safety concerns, clinician leadership in the organization should be engaged in assessing whether and how any particular recommended practice affects the organization’s ability to deliver safe, high quality care. Collaboration between clinicians and staff members while completing the self-assessment in this guide will enable an accurate snapshot of the organization’s patient identification status (in terms of safety), and even more importantly, should lead to a consensus about the organization’s future path to optimize EHR-related safety and quality: setting priorities among the recommended practices not yet addressed, ensuring a plan is in place to maintain recommended practices already in place, dedicating the required resources to make necessary improvements, and working together to prevent and mitigate the highest priority patient identification-related safety risks introduced by the EHR.

*Persons using assistive technology may not be able to fully access information in this file. For assistance, contact ONC at onc.request@hhs.gov.

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