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Patient Registration, Manual Entry

I. PRINCIPLE:

The Patient Registration screen provides access for manual entry of patient information into CLICS.

II. PROCEDURE:

  1. Open Patient Registration
    Click on the Patient Registration button located on the Lab Palette or choose “Patient Registration” from the Screens menu on the menu bar.
      
  2. Patient Search:
    1. Search by patient ID number:
      1. If known, type in the patient ID number and press ENTER.
      2. If the patient is in the LIS database under this number, the patient information will display. If no patient is found, a message displays telling the operator to check the search criteria and try again, click [OK] to return to the refreshed patient search screen.
    2. Search by patient name:
      1. TAB to the Last Name field and type in the patient's last name (for common last names also type in the first name and date of birth to further restrict the search) then press ENTER. If no patient is found, a message displays telling the operator to check the search criteria and try again, click [OK] to return to the refreshed patient search screen.
        Note: If the correct spelling of the patient's last name is in question, type in only the first few letters. Example Schmidt vs. Schmit or Schmitt; type in only “Schmi” to display all.
      2. A listing of all patients in the LIS database who match the search criteria will display.
        Note: If the same patient is listed, inappropriately, under more than one ID number, print the screen. Highlight the names, indicate that the patient records are possible candidates for merge and send the screen print to the LIS Project Coordinator.
      3. Select the desired patient:
        1. Press the up/down arrow keys until the patient name is high lighted, then press the ENTER key; or using the mouse, double-click on the correct patient name.
          In either case, the scroll window will disappear and the selected patient information will be displayed.
          Note: If the wrong patient is selected, return to the list of names based on the search criteria entered, by selecting Function on the menu bar and “Last Name Search” from the drop-down menu.
        2. If the patient is not found, a message will appear that will ask "Would you like to enter information on a new patient?". Move the pointer arrow over the desired response button “Yes” or “No” and click the left mouse button once. If Yes is selected the patient demographic entry screen will display with the search criteria entered auto-filling the appropriate field(s); if No is selected the screen will refresh for entry of new search criteria.
  3. Patient Demographic Entry: (all listed in TAB order)
    1. Patient ID: (required field)
      United Clinical Laboratories (UCL) does not require a Social Security Number (SSN) to order, process or bill for laboratory services.
      UCL collects the patient’s SSN for internal use only; e.g., record matching, etc. It does not appear on billing forms unless a particular insurance company demands it. Enter the SSN in the social security number field (SS#) of this screen only, DO NOT USE the patient's social security number as the Patient ID number.
      Type in the Patient ID number, if not auto-filled, and TAB to the next field.
      Note: There is a 14 character database limitation to the patient ID, consequently the patient ID cannot be longer than 14 characters in length.
      1. If an ID number is not provided by the ordering account, use Generate Patient ID under the Function menu to assign an ID number.
        1. Click on the “Function” menu on the menu bar and Select “Generate Patient ID”.
        2. A new patient registration screen will display with the computer assigned ID number.
          Notes: This procedure will be followed for all anonymous patient orders and replaces the procedure previously used for assigning ID numbers for these patients.
      2. If a record is found with the patient’s SSN as the ID number, create a new ID number using Generate Patient ID and send a merge request (include screen prints) to the LIS Project Coordinator to merge the record with the SSN as the ID number into the new record.
        Note: During CLICS downtimes the patient’s date of birth (DOB) plus initials may be used as an ID number.
        e.g., John X. Smith, birthdate January 5, 1959; ID = 010559JXS
    2. Last Name: (required field)
      Note: Once saved, the patient’s last name can only be changed by someone with a security level of 10 (I.T. staff). Send any changes to the I.T. Project Coordinator along with supporting documentation.

      Type in the patient's last name then TAB to the next field.
      1. Anonymous Patients:
        The “Last Name” field requires that the first character be a letter, therefore, in the “Last Name” field, type an X, followed by the account specific patient ID number, assigned by the referring station for an anonymous patient request.
        Example: Patient 123456789 would have the Last Name entered as X123456789.
      2. Veterinary Patients:
        The species followed by a dash and then the animal’s name is entered in the last name field.
        Example: Dog-Bailey
    3. First Name:
      Type in the patient's first name then TAB to the next field.
      Veterinary Patients: Type in either the “owner’s” last name or initial of first name followed by a space and then the last name.
      Example: M English
      The full name will appear as: Dog-Bailey, English or Dog-Bailey, M English.
    4. Middle Name:
      Type in the patient's middle name or initial, if available, and TAB to the next field.
    5. Phone Numbers:
      Type in the patient’s home phone number with area code. The patient’s work phone number may also be typed in, if available.
    6. Mailing Address: (listed in TAB order)
      1. Address 2:
        Type in the patient's deliverable address, i.e. Street or P.O. Box, in Address Line Two and TAB to the next field.
      2. Postal (Zip) Code:
        Type in the Zipcode. If the code is 9 digits do not enter the dash (-).
        Note: A Postal or Zip Code table is integral to the database.

        When a postal code is typed in and is recognized the City, State and Country fields will automatically fill after tabbing from the Postal Code field. If the postal code entered is not recognized the option is given to register a new postal code, a message appears “Postal code not on file, do you want to enter a new location?”, with options [Yes] to enter a new postal code or [No] to return to the screen.
        Note: Before creating a new postal code check to make sure the number entered is correct by clicking and dragging the message so that the zip code entered is in view. If the number is correct click [Yes] to register the new number, if the postal code entered in incorrect, click [No] to return to the field and correct the number entered.
        Entering a new postal code:

        1. Type in the name of the city, TAB to the next field.
        2. Type in the name of the state and TAB to the code field and type in the appropriate state code (2 digit abbreviation), TAB to the next field.
        3. Type in the country and TAB to the code field and type in the appropriate country code (e.g.: United States: USA, Canada: CAN, etc.).
        4. Click the [OK] button to save the entries. The [Cancel] button will close the “New Postal Code” entry screen without saving the data entered.
      3. Address 1:
        Type in any contributory address information, such as “in care of (c/o), etc” information, in Address Line One and TAB to the next field. If the patient address does not include contributory information leave the field blank and TAB to the next field.
    7. Sex:
      Use the directional arrows on the keyboard to select the radio button indicating the patient’s sex or using the mouse, click on the circular radio button indicating the patient's sex to fill the circle. TAB to the next field.
    8. Social Security Number:
      Type in the patient's social security number, if available, and TAB to the next field.
      Note: The dashes (-) are embedded text and are not to be entered manually.
    9. Birthdate/Age:
      Type in the patient's birthdate using two digits to express the month and day and four digits for the year (mmddyyyy), then TAB to the next field. The age will automatically calculate and display in the age field based on the birthdate entered.
      Note: The slashes (/) are embedded text and are not entered manually.
    10. Height:
      Type in the patient's height (in inches), if available, then TAB to the next field.
    11. Weight:
      Type in the patient's weight (in pounds), if available, then TAB to the next field.
    12. Species:
      If the correct species is human, TAB to the next field. If the patient is an animal, type in the first letter of the appropriate species (i.e.: H for Horse, C for Cat or D for Dog, etc.…) or using the mouse select the appropriate species from the drop down list.
      Note: The automatic default on species is human.
    13. Employment Status:
      Type in the first letter of the appropriate Employment Status (F for Fulltime or F again for Fulltime Student, P for Part-time or P again for Part-time Student, N for No, or O for Other) or using the mouse select the appropriate Employment Status from the drop down list, then TAB to the next field.
    14. Marital Status:
      Type in the first letter of the appropriate Marital Status (D for Divorced, M for Married, S for Separated or S again for Single, W for Widowed) or using the mouse select the appropriate Marital Status from the drop down list, then TAB to the next field.
    15. Patient Comment Field:
      Any pertinent comments regarding the patient can be added to this field. The comments added will be saved with other patient demographic data and viewable in future entries on this screen, as well as Order Registration, Patient Insurance, Order Maintenance and Archive Order Maintenance screens.
      Note: The comments DO NOT print on the requisition or any reports.
    16. Attending Physician: (required field)
      1. Open the doctor list: Using the mouse click once on the down arrow box to the right of the Attending Physician field.
      2. Insert the cursor in the search field and type in the first few (3 to 5) letters of the physician last name.
      3. Press the up/down arrow keys to select (highlight) the correct physician name on the drop-down list.
      4. Press the TAB key to accept the selected physician in the field and go to the next field.
    17. Patient Type:
      The default setting is Outpatient. All UCL patients whether they come in person or samples are sent from a client account are Outpatients, TAB to the next field.
      Note: There are other options available that are used only when the patient is a hospital patient and ADT information on the patient is transmitted over the hospital interface.
    18. Room #:
      Type in the patient room number, if applicable, then TAB to the next field.
    19. Bed #:
      Type in the patient bed number, if applicable, then TAB to the next field.
    20. Laboratory Alerts:
      If there are any pre-existing conditions of the patient that require special handling of the patient, the specimen and/or specimen acquisition this is documented by selecting from the list of Laboratory Alerts as follows:
      1. Locate the appropriate laboratory alert in the “Lab Alert Choices” field.
        Note: If the desired alert is not viewed in the displayed choices, use the scroll to locate the appropriate alert.
      2. Double-click on the desired alert and it will auto fill the “Lab Alerts Selected” field.
      3. If the desired alert is not included in either the list of choices or the selected alerts display screens then add the alert to the database as follows:
        1. Type the desired alert in the field labeled “Other”.
        2. Click on the Enter button, this will save the entry to the database.
        3. Go back to step T.a. above and select the alert.
    21. Save the information (Ctrl+s keys).
  4. Exit the Patient Demographic screen: press and hold the Ctrl+F4 function keys.
  5. If patient demographic information has not been saved, a message will display asking whether to save the information entered.
    1. If Yes, press Enter or using the mouse, click the “Yes” button. The modifications will be saved and screen will close.
    2. If No, press (Alt+n keys) or using the mouse, click the “No” button. The modifications will be discarded and the screen will close.
    3. To Cancel the command completely and return to the Patient Registration screen, click the “Cancel” button. Changes will not have been saved and additional changes can be made.
    1. 5-24-95 M. English
    2. 10-6-97 M. English (Revised: Format)
    3. 11-24-98 M. English (Revised: computer generated pt ID option; address lines 1 & 2 redefinition)
    4. October 1999 S. Hosch (Revised: II.2.B.a., II.3.I-J.)
    5. March 2001 M. English (Revised: CLICS version, section II: 1., 2.B.c.2.note., 3.J.note, 4.)
    6. October 2001 R. Theobald (Revised: II.2.A.a.)
    7. December 2001 M. English (Revised: guarantor/guardian verification)
    8. November 2002 M. English (Revised: II.3.B-C. clarification of name entry for veterinary patients)
    9. December 2005 M. English (Revised: for HIPAA compliance)
    10. February 2007 M. English (Revised: d’c use of SSN as patient ID)
    11. July 2008 M. English (Revised: II.3.T. lab alerts added)
    12. October 2010 M. English (Revised: country added to patient address)

Comprehensive Review:

Interim Review:
June 2010 S. White (no changes)
July 2011 R. Theobald (Revised: 9 character pt ID limitation changed to 14)

       

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