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Patient Identification (3.2.1)

Patient Identification (3.2.1) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Medical Record

3.2.1


UW HEALTH CLINICAL POLICY 1
Policy Title: Patient Identification
Policy Number: 3.2.1
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: June 26, 2015

I. PURPOSE

To provide for proper patient identif ication prior to any procedure, treatment or medication administration.

II. POLICY ELEMENTS

All inpatients on admission, all Emergency Department patients or outpatients requiring sedation for
treatment or procedures, patients receiving chemotherapy, and patients requiring blood products must be
identif ied w ith a barcode identif ication (ID) band (displaying medical record number, patient’s f irst and last
name and birth date) w orn on their w rist (preferred) or ankle to maintain positive ID. Prior to any procedure,
treatment or medication administration, healthcare providers assure positive patient identif ication by using at
least tw o patient identif iers, patient’s f irst and last name and medical record number or birth date.

III. PROCEDURE

A. Application of the Band
i. Identif ication bands are prepared for inpatients by the Admissions Department if the patient
presents in the Admissions Department. For patients w ho bypass admissions, all nursing care units
and all outpatient phlebotomy sites, have the capability to create identif ication w ristbands. All
patients not receiving a w ristband in Admissions must receive one on their nursing unit.
a. The band is placed on either w rist w ith the name facing the hand so it is readable by a
person holding the patient’s hand. The second choice is either ankle.
b. When the ID band is placed on the patient, the f irst and last name and birth date on the
band should be confirmed w ith the patient or patient’s authorized representative. If the
patient is not competent to confirm his/her ow n identif ication and no relative or guardian is
available, another person w ho know s the person should confirm identif ication and w itness
application of the band. If the patient identity is not confirmed, refer to UWHC policy 8.29,
Unidentif ied Patient.
c. If the patient’s condition prohibits application of the identif ication w ristband to a limb, (e.g.,
severe burns) only then may the w ristband be applied to the foot of the patient bed. This
exception should be documented in the medical record. At no other time may a w ristband
be attached to the foot of the bed. It is also prohibited to have a w ristband loose in the
patient room or attached to any other furniture/equipment. If the patient must be
transported outside of the bed to another area of the hospital (e.g., for diagnostic tests,
treatment, etc.), the identif ication band should be removed from the foot of the bed and
attached to the patient in some prominent manner such as pinning it to the patient’s gow n.
Upon return, the identif ication band is removed from the patient’s gow n and replaced at
the foot of the bed.
ii. Outpatients that are presenting for any procedure or treatment requiring sedation in these locations
must have an identif ication band.
a. Identif ication bands are prepared in the Outpatient Surgery Center, Ambulatory Procedure
Center, Chemotherapy Treatment Room, Cancer Clinic Lab, or may be obtained by calling
the Admissions Department.
b. The staff member completing the pre-procedure patient assessment w ill then apply the ID
band as in 1.a. and 1.b. above.
iii. Patients in the Emergency Department or admitted from the Emergency Department or Clinics to
the Inpatient Service or Operating Room.
a. The Emergency Department Coordinator (EDC) w ill prepare Emergency Department ID
bands for patients treated in the Emergency Department. The band w ill be applied by the
EDC in the ED registration area (unless this is not possible due to type of injury) or by
nursing staff for all other patients including those patients arriving by ambulance or Med
Flight.
b. All patients presenting to an inpatient unit from the Emergency Department or any
Operating Room must have an identif ication band in place prior to trans fer of care.



UW HEALTH CLINICAL POLICY 2
Policy Title: Patient Identif ication
Policy Number: 3.2.1

c. Patients admitted to the hospital through the clinics are directed to the Admissions
Department w here ID bands are aff ixed. If the patient needs to go directly to the inpatient
unit, the nursing unit w ill identify the patient as per i.a. and i.b. above, and create and
apply the identif ication w ristband. The patient’s relative or signif icant other is directed to
the Admissions Department to complete the admission interview .
B. Use of the Band
i. Staff in each hospital department must use the band to identify patients prior to care or treatment,
e.g., operative procedures, blood transfusions, laboratory procedures, diagnostic procedures,
medication administration, treatment, serving trays, etc. Proper identif ication is made by reading
the name on the hospital forms and comparing the f irst and last name and medical record number
w ith that on the identif ication band.
ii. Any person accompanying the patient off the unit should confirm that the identif ication band is
properly placed, legible and correct. If the patient does not have a band in place, the nurse
responsible for the patient (or Health Unit Coordinator) must obtain and apply a band before the
patient leaves the unit.
iii. If the identif ication band must be removed from the patient’s limb for line placement or any other
reason the follow ing steps are recommended:
a. Before old ID band is cut off have new ID band made.
b. Verify that information on the new and old ID bands match. If not, resolve the discrepancy
before proceeding.
c. Apply new ID band on an alternate limb per policy.
d. Cut off old ID band.
iv. When it is necessary for the identif ication band to be removed in the operating room during a
surgical procedure, a new band must be applied in accordance w ith this policy before the patient
leaves the operating room.
v. Staff should be alert to the need to keep the band loose enough to move freely and the skin
beneath the band dry to prevent irritation.
C. Patients w ith Like or Similar-Sounding Names
i. When patients w ith like or similar-sounding names are admitted to the same patient care area,
caution must be used to assure the right patient is identif ied. In Health Link, patients w ith similar
names w ill be boldfaced and italicized on the nursing unit census. Avoid placing patients w ith like or
similar-sounding names in adjacent rooms.

IV. FORMS

Identif ication band in child or adult size (ALL bands are non allergenic, non toxic).

V. COORDINATION

Author(s): Director of Nursing
Senior Management Sponsor: Sr. VP Patient Care Services and CNO
Review ers: HUC Trainer; Admissions; Emergency Department; Chemotherapy Clinic; Pediatrics; Nursing
Informatics
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: May 18, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospital and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Ronald Sliw inski
UWHC President and CEO

Teresa Neely



UW HEALTH CLINICAL POLICY 3
Policy Title: Patient Identif ication
Policy Number: 3.2.1

Chief Ambulatory Administrative Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

UWHC policy #8.29, Unidentif ied Patient Policy
UWHC policy #8.59, Chemotherapy Processes: Informed Consent, Ordering, Verif ication, Administration,
Documentation and Patient/Family Education
Nursing Administrative policy 10.19, Medication Administration Using Scanning Technology

VIII. REVIEW DETAILS
Version: Revision
Next Revision Due: June 26, 2018
Formerly Know n as: Hospital Administrative policy #7.31