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Policies,Clinical,UW Health Clinical,Medical Records and Communication,Medical Record

Unidentified Patient (3.2.7)

Unidentified Patient (3.2.7) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Medical Record

3.2.7


UW HEALTH CLINICAL POLICY 1
Policy Title: Unidentified Patient
Policy Number: 3.2.7
Category: UW Health
Type: Inpatient
Effective Date: October 25, 2016

I. PURPOSE

Provide a process to rapidly register a patient for treatment and/or admission and ensure the accurate
identification of these patients throughout their hospitalization.

II. POLICY ELEMENTS

This policy will provide direction for rapid admission of an unidentified and/or disaster patient to the
Emergency Department or UW Health Inpatient Units. The policy will also provide a process for identification
of an unidentified patient and management of the patient medical record.

III. PROCEDURE

Unidentified Patient Assignment
A. Unidentified patients requiring rapid processing in the Emergency Department or within the UW Health
Inpatient Units will be admitted and assigned a Health Link pre-created unidentified name. Pre-created
unidentified names within Health Link will be assigned as an alias name with a naming convention of First
Name "Unidentified" and Last Name "a state or country." Example: XXWisconsin, Unidentified.
Two hundred pre-created unidentified names are available for assignment in the Health Link system and can
cycle through repeatedly by adding a number to the name after the initial assignment. Example:
XXWisconsin1, Unidentified.
B. The Emergency Department Coordinator (EDC) will register the unidentified patient utilizing Health Link
arrival. Health Link auto-assigns an unidentified patient name and new medical record number (MRN) based
on the pre-created unidentified naming convention list. The EDC will also place a Chart Alert indicating that
the current encounter began with the patient as "XXWisconsin, Unidentified." This alert will be utilized for
cross-reference purposes and will be removed soon after discharge by Health Information Management
(HIM) staff.
i. In the instance of a direct transport from Med Flight to the University Hospital Operating Room, the
Med Flight Communications Coordinator will contact the EDC to create the unidentified patient
registration.
ii. The EDC will create the unidentified patient record. When requested by the OR, the EDC will print
and tube a wristband to the OR. If needed, the OR staff may print a wristband and place on the
patient.

Identification of Unidentified Patient
A. Health Team Members may use a variety of sources (i.e., contacting family by phone, wallet or purse
contents, corresponding photo ID) to assist in locating information that may confirm identification of the
patient.
B. Positive identification can be made by the patient who is alert and oriented or by direct visual contact from a
family member or personal acquaintance. The health team member obtaining this information must
document in the patient's chart the following:
i. Name and relationship of the person(s) who made the positive identification.
ii. The patient’s name and birth date.
C. When visual identification cannot be made the only other acceptable methods of identification are dental
records or fingerprints from the police. A patient will remain unidentified indefinitely until the patient is able to
identify himself or visual identification becomes possible, dental records or fingerprints are attained.

Identification Change in Health Link
A. Upon positive identification of the patient the Care Team Leader/Senior Team Member/Charge Nurse will
notify Admissions Bed Control (ED Coordinator during off-hours) to enter the patient name and date of birth
into the temporary fields 'Preferred Name' and 'Permanent Comments' fields until a Unidentified Name
Change order has been signed by the Attending Physician.
B. The Attending Physician will write the Unidentified Name Change order when the patient identification is
complete and there is a decision of definitive care and/or the patient has reached the nursing unit of



UW HEALTH CLINICAL POLICY 2
Policy Title: Unidentified Patient
Policy Number: 3.2.7

definitive care. This order also contains the following conditions:
i. The patient has been positively identified by one of the methods listed in the order (Self – Alert and
Oriented x 3, Family, Personal Acquaintance, Dental Records, Fingerprints).
ii. The patient is not currently receiving blood or blood products.
iii. The patient is not en route to the Operating Room.
iv. This order has been signed by an Attending Physician.
C. If a patient expires while still assigned as an unidentified patient the nursing unit or procedure area will
contact Admissions with the positive identification information to update the patient records.
D. Upon the Attending Physician signing the 'Unidentified Name Change' order, the order will print in Bed
Control - Admissions or the Emergency Department during off-hours. Admissions Bed Control/EDC will
update the patient demographics and remove the 'Preferred Name' information.
E. Admissions Bed Control/EDC will complete patient Links notification via Health Link to HIM as appropriate
when the patient has a previous medical record number.
F. Once the demographics have been updated in Health Link the nursing unit will print and apply a newly
generated wristband to the patient.
G. Upon receiving notification of duplicate MRN assignment, HIM will verify records merge requirements and
place a duplicate MRN chart alert on the patient record as soon as possible. This alert will notify staff and
clinicians that additional medical history exists under another MRN. This alert will remain visible until a
records merge can be safely completed.
H. Whenever possible, HIM will complete merges after patient discharge. When requested, HIM staff will
attempt to complete the records merge during hours of low activity and will alert the nursing unit staff by
phone in advance of locking the records. All clinicians must be logged off of the patient record in order for
the merge to transpire. HIM staff will coordinate merges with Clinical Labs and ancillary systems so systems
are merged promptly. All patient orders will be maintained and all documentation will be merged into a single
record.
I. Upon discharge of the patient, HIM will receive the patient discharge information via workque report to
remove all chart alerts.
J. A Health Link report will be monitored monthly by the Admissions Supervisor in the Emergency Department
to ensure that all unidentified patient information has been updated.
K. During computer downtime and/or internal disaster situations paper documentation for the Unidentified
Patient will be maintained in the Emergency Department. As Health Link recovers, all paper documentation
will be scanned according to UW Health clinical policy #3.2.6, Inpatient Health Link Downtime and Recovery.

IV. COORDINATION

Author: Director, Emergency Services
Senior Management Sponsor: VP, Professional Services
Reviewers: Director, Access Services; Clinical Nurse Manager, Emergency Department; Trauma
Subcommittee; Director, Health Information Management; Director, Clinical Labs; Director, Radiology;
Manager, Surgical Services
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: August 15, 2016

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 Hospitals 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.

V. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

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

VI. REFERENCES



UW HEALTH CLINICAL POLICY 3
Policy Title: Unidentified Patient
Policy Number: 3.2.7


UW Health clinical policy #3.2.6, Inpatient Health Link Downtime and Recovery

VII. REVIEW DETAILS

Version: Revision
Next Revision Due: October 2019
Formerly Known as: Hospital Administrative policy #8.29