ATTACHMENT 11- LEXINGTON VAMC PATIENT IDENTIFICATION MEMO.pdf

VA MEDICAL CENTER

LEXINGTON, KENTUCKY

MEMORANDUM NO. 00Q-11

June 4, 2018

PATIENT IDENTIFICATION

1. PURPOSE: To outline the policies and procedures for the accurate identification of Veterans. A system for patient identification provides positive identification of all Veterans, and provides a positive method for linking patients to their medical records and treatment;

minimizes the possibility that identifying data can be lost or transferred from one patient to another; and improves accuracy of patient identification.

2. POLICY: All employees, residents, and students will positively identify patients prior to beginning any encounter, delivering any care or other health related services.

a. Positive identification of the patient is ensured by having the patient, family member or significant other verbalized the patient’s full name and full social security number. Although access to electronic patient records is obtained through use of the first initial of the patient’s last name and last four digits of the social security number (SSN), these are NOT the patient identifiers. This information will be matched to the patient’s record.

b. Patient identification wristbands are used in high risk patient care areas such as surgery, inpatient, chemotherapy infusion, dialysis, endoscopy, cardiac catheterization lab, and any outpatient setting performing invasive procedures or conscious sedation.

3. DEFINITIONS: None

4. RESPONSIBILITIES:

a. Medical Center Director is responsible for establishing the policy for patient identification.

b. Chief of Staff and Associate Medical Center Director for Patient Care Services are responsible for ensuring that clinical services are in compliance with the policy for patient identification.

c. Supervisors, Managers, and Service Chiefs are responsible for ensuring training and compliance with this policy.

d. Patient Safety Manager receives and reviews reports of adverse events and near misses related to patient identification errors for process improvement opportunities.

e. All Employees having patient contact are responsible for correctly identifying patients.

5. PROCEDURES:

a. Patients are positively identified prior to any process or communication; examination or procedure; administration of medication; administration of blood or blood products; treatment;

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or specimen collection. The method of identification eliminates the likelihood of errors that can harm patients and maximizes patient safety. Two identifiers are utilized.

b. Each patient encounter begins with positive identification of the patient. This is accomplished through active communication. Patients are asked to state their full name and full social security number. This information must be matched to a hard copy document or computer screen containing information related to care, treatment, and services to be provided. Passive communication techniques such as, “Are you Mr. Jones? Is your date of birth July 23, 1944?” are NOT used when establishing patient identity.

c. In outpatient areas, it is acceptable to use first initial of the patient’s last name and the last four digits of the social security number (SSN) to locate the patient in the electronic medical record during check in. While it is acceptable to use the first initial of the last name and the last four of the social security number to reference the patient’s electronic medical record, under no circumstances should staff use the last name and last four as the patient identifiers for the exchange of any clinical health information, examining, ordering preparing, dispensing, or delivering any care.

(1) Once the record is open, staff will utilize the patient’s Veteran Identification Card (VIC) and compare the information to the electronic record for a match. The patient’s full name and social security number are used if the patient does not have a VIC Card or photo identification.

(2) In addition, the patient will be asked to provide their current address and telephone number to verify their record is accurate.

(3) The Pathology & Laboratory Medicine Services use the full name and full social security number.

(4) Visual recognition and/or geographic address may be used as a method of patient identity ONLY for established patients seen in the Home Based Primary Care Program and Behavioral Health Staff making Community Visits.

d. Wristbands that are applied to a patient are double-checked for accuracy. Medical staff will ask the patient to state their full name and full SSN, before applying the wristband.

e. Inpatients are identified by means of a non-transferable wristband that remains in place, physically on the patient, during the course of care. When the patient’s clinical or mental condition prohibits the ability to maintain the wristband on the upper extremity, alternative methods for affixing the wristband to the patient are considered. The wristband is checked for legibility at each patient interaction. Any employee who observes a missing or unreadable and/or unscannable wristband must report this to the unit manager or charge nurse who coordinates the production and attachment of a replacement following verification of the patient’s identification.

f. Bed or room numbers are NOT used as a means of patient identification.

g. In the event the patient, family, or significant other cannot or will not communicate their

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full name and social security number, the patient’s identity must be confirmed using a Primary Identification Document (Attachment A). If the patient does not have a valid Primary Identification Document, the patient must be asked to provide two secondary identification documents or answer a series of verifiable challenge questions.

h. Each provider of service positively identifies the patient at each encounter. Medications, treatments, and services are not provided unless the patient has been positively identified and matched to the service being provided.

i. Two patient identifiers are used when communicating critical value results.

j. Prior to the start of any surgical/invasive procedure, a final verification timeout is conducted to confirm the patient’s identity using the full name, full SSN, the correct procedure, and the correct site. Surgical procedures also verify the correct implant and imaging, as appropriate. Blood and tissue specimen labels must contain the patient’s full name and full SSN and verification of this information must occur.

k. If an unresponsive patient must be assigned a temporary name (e.g., John Doe) and temporary identifiers, these identifiers can be used to identify the patient and match against specimen labels, medications ordered, or blood product labels. Formal identification occurs as soon as possible. Once the patient’s true identity is confirmed, the temporary identifying information is replaced by the identifying information.

6. REFERENCES: The Joint Commission Comprehensive Accreditation Manual for Hospitals (2016), National Patient Safety Goal NPSG.01.01.01; The Joint Commission Comprehensive Accreditation Manual for Long Term Care (2016), National Patient Safety Goal NPSG.01.01.01; The Joint Commission Comprehensive Accreditation Manual for Behavioral Health (2016), National Patient Safety Goal NPSG.01.01.01; The Joint Commission Comprehensive Accreditation Manual for Home Care (2016), National Patient Safety Goal NPSG.01.01.01; Policy Memorandum No. 00-2, Patient Safety Improvement Program; The Universal Protocol, The Joint Commission Comprehensive Accreditation Manual for Hospitals (2016);

7. FOLLOW UP RESPONSIBILITY: The Patient Safety Manager is responsible for the contents of this Policy Memorandum

8. RESCISSION DATE: Policy Memorandum No. 00-24, Patient Identification, dated October

15, 2015.

9. RECERTIFICATION: This Policy Memorandum will be recertified on or before June 4, 2023.

Emma Metcalf, MSN, RN Director

MEMORANDUM NO. 00Q-11

APPENDIX A

PROOF OF IDENTIFICATION DOCUMENTS

1. Primary Identification Documents. The following are sources of identification (ID):

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NOTE: The identification must be current, valid, and contain, as applicable, a recognizable photograph.

a. State issued Drivers License,

b. State issued ID,

c. United States (U.S.) Passport (Non-citizens may provide a foreign passport),

d. Veteran Health Identification Card (VHIC),

e. Military ID Card (DD Form 2 or DD Form 1173),

f. Temporary Resident ID Card (I-688),

g. Resident Alien Card (old version of I-551),

h. Permanent Resident Card (current version of I-551), or

i. Other Federal or State issued ID.

2. Secondary Identification Documents. Two of the following documents are required for initial verification, if a primary document is not available.

a. Certified Birth Certificate,

b. Social Security Card (original, not a metal or plastic facsimile),

c. Department of Defense Form DD214, Certificate of Release or Discharge from Active Duty; or equivalent certificate issued by a uniformed service, Department of Defense, or War Department containing the full name of the service member, branch of service, active duty or reserve status, beginning and ending dates of service, and character of discharge,

d. Marriage License (certified copy of license filed with the clerk of court),

e. Voter Registration Card,

f. Student ID Card,

g. Native American Tribal Document,

h. Certificate of U.S. Citizenship (Immigration and Naturalization Service (INS) Forms N-560, N-561, or N-645);

i. Certificate of Naturalization (INS Forms N-550, N-570, or N578), and

j. Any of the following certificates issued by US Consular Offices documenting the birth of a child on foreign soil to a US citizen:

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(1) Certification of Birth Abroad (FS Form 545),

(2) Certification of Birth Abroad (DS Form 1350),

(3) Certification of Report of Birth,

(4) Consular Report of Birth Abroad (FS Form 240), or

(5) Report of Birth: Child Born Abroad of American Parent or Parents (DS Form 240).

NOTE: If a name change has occurred as a result of marriage, divorce, court order, or as part of the naturalization process, official documentation is required.

3. Challenge Questions. These questions are to be used to authenticate a Veteran’s identity when no acceptable Primary or Secondary Identification Documents are available, or when requests are received by telephone.

a. Staff must ask questions that are verifiable through existing Veterans Health Information and Technology Architecture (VistA) entries, Hospital Inquiry (HINQ), Veterans Information System (VIS), or other reliable sources. Ask only as many questions as necessary to positively authenticate the Veteran’s identity (usually three or four), however, full legal name, including middle name (if one exists), is a required question and must be asked in addition to at least two of the following questions.

b. Ask the Veteran, or person acting on behalf of the Veteran, to provide the Veteran’s:

(1) Full legal name, including middle name,

(2) Social Security Number (SSN), NOTE: Although VA has indicated it will not call a Veteran and ask for a SSN, it is allowable to ask for a SSN when the Veteran (or someone on the Veteran’s behalf) initiates the call or is presenting in person.

(3) Military Service Number,

(4) VA Claim Number,

(5) Branch of service and service dates,

(6) Birth date, including year,

(7) Place of birth, the city and state,

(8) Home address,

(9) Spouse’s name,

(10) Mother's maiden name,

(11) Next of kin.

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4. Sample Scenarios. The following is a table of the different scenarios that may take place and the action that is to be taken by the person on staff asking the challenge questions.

Scenario Action 1 Veteran refuses to answer question. Ask another question.

2 Veteran does not remember (e.g., Military

Service Number).

Ask another question.

3 Veteran refuses to answer all questions, cannot remember the answers to the three or four questions, or answers incorrectly.

Care will not be provided, unless emergent care is required, until identification can be verified.