Medical Records Patient Tab

The Patient tab is used to add or update the patient’s address/contact information, special designations (smoker, diabetic, etc.), employment, emergency contact, and alert information. Most patient demographic information is patient-level information, meaning it is carried forward automatically to future visits. Employer information and the Publish designation are visit-level information.

Information entered here can be used to record contact information and emergency contacts, for reporting purposes, for booking people with similar ethnicity and language in the same rooms, or to trigger automatic conflict checks when ordering items for the patient.

To update patient information, follow these steps:

1. Last, First, and MI – Enter the person’s name.
2. Sex – Click the dropdown and select the patient’s sex.
3. URN – Displays the Unit Record Number.
4. MRN – Displays the Medical Record Number.
5. DOB – Click the field to enter the birth date directly or to select from a calendar. The Age field is automatically calculated.
6. SSN – Enter the patient’s Social Security Number.
7. Marital – Click the dropdown and select a marital status.
8. Street – Enter the mailing address. Information can be entered on multiple lines.
9. Perm/Local – The Perm option is selected by default and defines the patient’s permanent address. Click the Local option to enter a temporary address. When Save is clicked to save the information, if only one address is defined, a message displays asking if the address should be copied to the undefined option. Any change to the primary address updates the local to match the primary.
10. Email – Enter a valid e-mail address.
11. City – Begin to enter the city name. An autocomplete list with all cities (listed with state and zip code) matching the entered letters displays (after two letters are entered). Click on a description to select it. The City, State, and Zip Cd fields are automatically populated with the selected city information.
12. State – Click the drop-down and select the state.
13. ZIP Cd – Enter the ZIP code for the address (The City and State fields automatically populate.) or begin to enter the name of the city in the City field. An autocomplete list with all cities matching the entered letters displays (after two letters are entered). Click on a city to select it. The State and ZIP/PC automatically populate.
14. Phone/Cell – Enter the phone number, including the area code, into the field.
15. Race – Click the drop-down menu and select a race.
16. Lang – Click the dropdown and select a language.
17. County – Click the dropdown and select a county.
18. Religion – Click the dropdown and select a religion.
19. Adv Direct – Click the dropdown and select an advanced directive option.
20. Smoker Status – Click the dropdown and select an option. The options provide detailed smoker information and match federal requirements.
21. Ethnicity – Click the dropdown and select the patient’s ethnicity.
22. Culture – Click the dropdown and select the patient’s culture.
23. Diabetic – Check to designate the patient as a diabetic. If Scheduling is being used, order conflict checking can be set up to post warnings when certain items are scheduled for a diabetic patient.
24. Publish – Check to display the patient’s name in patient or visit search results in Registration or Medical Records.

    Note: When unchecked, “CONFIDENTIAL” displays instead of the patient’s name in the search results or work queue list unless the user has the CONF security right. If the user has the security right, names are published but are highlighted in yellow.

25. Donor – Check to designate the patient as an organ donor.
26. Click Save.

Note: If the patient is also the guarantor or insurance subscriber, a warning message displays asking the user if he or she wants to also update the guarantor and subscriber information. Click Yes to update the guarantor and subscriber information. Click No to only update the patient information.

Relatives

The Relatives tab lists emergency contacts or other people related to the patient (spouse, parent, employer, etc.). Relatives can be added, updated, deleted, or ranked in order of who should be contacted first in an emergency. Relatives defined here can be selected as guarantors and subscribers in other tabs.

To add a relative, follow these steps:

1. Click the Add button . A row is added to the list, and the Rel to Pat menu is enabled.

2. Rel to Pat – Click the drop-down menu and select the person’s relationship to the patient. The remaining fields are enabled.
3. SSN – Enter the person’s Social Security number.
4. Last, First, and MI – Enter the relative’s name information. The first and last name fields are required.
5. City – Begin to enter the city name. An autocomplete list with all cities (listed with state and zip code) matching the entered letters displays (after two letters are entered). Click on a description to select it. The City, State, and Zip Cd fields are automatically populated with the selected city information.
6. State – Click the drop-down and select the state.
7. ZIP Cd – Enter the ZIP code for the address (The City and State fields automatically populate.) or begin to enter the name of the city in the City field. An autocomplete list with all cities matching the entered letters displays (after two letters are entered). Click on a city to select it. The State and ZIP/PC automatically populate.
8. Phone/Cell/Work – Enter the phone number, including the area code, into the field.

9. Address Same as Patient – Check if the person’s address is the same as the patient’s. The address information is automatically populated based on the patient’s information.
10. Emergency Contact – Check if the contact is an emergency contact and will be noted as such in the Relatives tab (with the EC box checked in the list). A patient can have multiple emergency contacts.
11. Guardian – Check if the contact is the patient’s guardian.
12. DOB – Enter the birth date. Enter a four-digit year for a birth date prior to 1951; otherwise, enter a two-digit year.
13. Death – Enter the death date. Enter a four-digit year for a birth date prior to 1951; otherwise, enter a two-digit year.

14. Click Save.

Update Relatives

To update a relative or contact, follow these steps:

1. Click on a relative in the Relatives list to select it. The detail fields are enabled.
2. Make any necessary changes.
3. Click Save.

Delete Relatives

To delete a relative or contact, follow these steps:

1. Click on a relative in the Relatives list to select it.
2. Click the Delete button . The contact is deleted from the list.
3. Click Save.

Rank Relatives

If the patient has multiple relatives/contacts, they can be ranked in order of priority for reports and admit forms. To rank contacts, follow these steps:

1. Click on a contact in the Relatives list to select it.

2. Click the up  arrow or down  arrow to re-rank the contact.

3. Click Save.

Allergies

The Allergies tab displays any allergies associated with the patient and can be used to add and delete allergies. Allergy information is used to automatically check for conflicts with items, supplies, etc. Allergies can be added to the patient record by using existing allergy codes or by entering free-form text.

To add an allergy, follow these steps:

1. Click the Add button. A row is added to the list, and the Allergy Cd and Freeform fields are enabled.
2. Enter the allergy by one of the following methods:
   • Allergy Cd – Enter an allergy code in the first field or an allergy description in the autocomplete field (clicking a suggested description to select it).

• • Freeform – Enter free-form text into the field.

3. Click Save.

Delete Allergies

To delete an allergy, follow these steps:

1. Click on an allergy in the list to select it.
2. Click the Delete button . The allergy is deleted from the list.
3. Click Save.

AKA/Maiden

The AKA/Maiden tab lists any alias or maiden names associated with a patient’s URN. RCM Cloud^® tracks name changes for a patient automatically. The current and AKA/maiden name information is used for patient searches throughout RCM Cloud^®. Along with the AKA/Maiden name, the window lists the date the name was changed in the system.

An AKA/maiden name can also be added directly in the tab.

To add an AKA/maiden name, follow these steps:

1. Click the Add button . A row is added to the AKA/Maiden with the current date defaulted as the Effective Through date, and the name fields below the list are enabled.

2. Enter the new name information.

3. Click Save.

Alert Codes

The Alert Codes tab displays pertinent information (physical condition, VIP status, etc.) regarding the patient. Alerts added here also display in the Patient Data Panel. Alerts can be assigned at the visit or patient level or both. Patient-level alerts carry forward with the patient, while visit-level alerts are specific to the visit.

To add an alert, follow these steps:

1. Click the Add button . A row is added to the list and the Alert Type drop-down menu is enabled.
2. Alert Type – Click the dropdown menu and select the alert code type:

• Patient Alert Code – Select this option to add the alert at the patient level. The dropdown contains only alerts that are set up as patient alerts or both.
• Visit Alert Code – Select this option to add the alert only to the specific visit. The dropdown contains only alerts that are set up as visit alerts or both.

3. Alert Code – Click the dropdown and select an alert.

Note: If the alert code Restricted is selected, the patient will be noted as restricted on admit forms.

4. Click Save. The alert is saved and added to the Patient Data Panel.

Delete Alerts

To delete an alert, follow these steps:

1. Click on an alert in the list to select it.
2. Click the Delete button . The alert is deleted from the list.
3. Click Save.

Expiry

The Expiry tab is used to add or update patient death information, including the date and preliminary cause.

To add death information, follow these steps:

1. Death Date – Click the field to enter the date directly or click to select a date from a calendar. Then enter the time directly or click the clock icon to select a time.
2. Prelim. Cause – Enter the patient’s preliminary case of death.
3. Location – Enter the location for the patient’s death.

4. Click Save.