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Policies,Clinical,UWHC Clinical,Department Specific,Radiology

Patient Identification - Radiology (1.01)

Patient Identification - Radiology (1.01) - Policies, Clinical, UWHC Clinical, Department Specific, Radiology

1.01

POLICY & PROCEDURE



Effective Date:
12/1/2012
 Administrative Manual
 Nursing Manual
 Other: Radiology Department
Policy #: 1.01

 Original Revision Page 1 of 1 Title: Patient Identification - Radiology

I. PURPOSE
To provide for proper patient identification and ensure that the intended radiology procedure is performed on the correct
patient.

II. POLICY
Patient identification is critical to ensure that the correct patient receives the right treatment, diagnostic examination,
medication, invasive/non-invasive procedure, blood products, and also to reduce the chance of unnecessary radiation
exposure. Radiology staff will correctly identify all patients using two patient identifiers prior to a procedure or examination.
The technologist who administers radiation or performs the ultrasound, MRI or Nuclear Medicine examination is ultimately
responsible for patient identification; this specifically references the person controlling the initiation of image acquisition. The
technologist or RN who administers a radiopharmaceutical or medication is ultimately responsible for patient identification.

III. PROCEDURE
A. Inpatients
1. Following check in and for all inpatients, in the examination, procedure, prep area, or bed-side the staff member
receiving the patient will verify identification with patient (or, if patient unresponsive, person(s) accompanying
patient) using two patient identifiers. The procedure/examination being performed will be verified using the
electronic health record.
2. If a caregiver hand-off occurs, the verification process must be repeated using two patient identifiers.
3. All members of the care team must actively communicate to ensure that the patient has been accurately identified
and the procedure/examination is intended for the patient.
4. The technologist who administers radiation or performs the ultrasound, MRI or Nuclear Medicine examination is
ultimately responsible for patient identification; this specifically references the person controlling the initiation of
image acquisition. The technologist or RN who administers a radiopharmaceutical or medication is ultimately
responsible for patient identification.

B. Outpatients
1. The radiology staff person retrieving the patient from the waiting area/clinic room will immediately verify
identification of the patient using two patient identifiers. If the patient is unable to provide responses to verification
questions, the patient’s identity must be verified by a family member or escort.
2. Upon arrival to the examination, procedure, or prep area the procedure/examination being performed will be
verified using the electronic health record.
3. If a caregiver hand-off occurs, the verification process must be repeated using two patient identifiers.
4. All members of the care team must actively communicate to ensure that the patient has been accurately identified
and the procedure/examination is intended for the patient.
5. The technologist who administers radiation or performs the ultrasound, MRI or Nuclear Medicine examination is
ultimately responsible for patient identification; this specifically references the person controlling the initiation of
image acquisition. The technologist or RN who administers a radiopharmaceutical or medication is ultimately
responsible for patient identification.

IV. COORDINATION
Author: Business Operations Manager, Radiology
Sponsors: Director, Radiology; Senior Vice-Chair, Radiology; Vice-Chair Quality, Radiology
Review/Approval: Radiology Quality, Safety and Innovation Committee