Patient Identity team ensures the records match the patients – and vice versa

Always a critical part of patient care, the Patient Identity division of Health Information Management works diligently across Yale New Haven Health to ensure every patient’s personal information is accurate and secure.

Established in 2012 just before the Epic go-live, the division’s primary responsibility is helping Epic users with patient safety issues, said Maria Michelangelo, manager. These issues include updating information that was entered inaccurately during patients’ arrival; helping clinical staff with documentation errors; merging duplicate medical record numbers; and handling issues related to identity theft or insurance fraud.

Identifying patients accurately and matching them with the correct treatments or services are key to preventing medical errors, which is why The Joint Commission emphasizes correct patient identification as a national safety goal. Patient Identity’s work is complex, especially when patients arrive at the hospital unconscious and cannot be identified. Once the identity is known, a care team or Patient Registration staff member asks Patient Identity to update the patient’s information.

“This is just one example of numerous protocols we’ve developed in collaboration with stakeholders to ensure accuracy of the medical record, patient data and clinical documentation,” Michelangelo said.

Two areas sometimes overlooked are the division’s role in records for adopted patients and those arriving under aliases.

“For adopted patients who don’t want information about their history revealed, we can use Epic tools to put that information into a closed record, while opening a new record for the post-adoption,” Michelangelo said. “Aliases can be used to conceal patients’ identities in cases involving the Department of Children and Families or situations involving imminent risk.”

In addition, Patient Identity recently centralized the responsibility of updating patients’ “alive” or “deceased” status in the medical record.

Of course, the Patient Identity team needs everyone’s help to keep records accurate. Staff should always ask these questions when recording patient information:

• Do you need to update patient status from alive to deceased?
• Has the wrong patient been selected in Epic?
• Do you need a duplicate medical record merged?
• Is there a document or order that needs to be corrected?
• Do you suspect identity/insurance fraud with a patient?

If staff answer “yes” to any of these questions, contact: Patient Identity, [email protected], 203-688-2240.