USER`S MANUAL - THE FIELDS IN OUTPATIENT REGISTRATION
Contents
1. if semi private insurance coverage is covered by someone other than the patient i e parent husband etc you must enter that person s employer here You will be able to indicate the name relationship when completing screen 2 of the Ins 2 information PAGE SCREEN 4 INSURANCE INFORMATION INSURANCE COMPANY name will default in from page 3 POLICY If Insurance 1 is OHIP Policy shows the HCN entered on Page 2 but the cursor bypasses this field if a HCN change is needed it has to be done on screen 2 if the HCN is unavailable the query lines at the bottom of this screen allow explanation of how this info will be obtained you may see the HCN listed in the query lines as prior to 1 Jul 91 staff at OGH recorded this information here for the OHIP insurance please enter the name exactly as it appears on the Health Card at the Subscriber prompt The remainder of the prompts on this page are not necessary unless you are aware of eg an expiry date shown on the card Press F12 to quickly reach the bottom of the page For other primary insurances such as other province or out of country follow the insurance queries They will prompt you with the required information If Insurance 1 is WCB for WSIB Enter the Claim number if known but leave BLANK for new cases such as in Emerg where a Claim number will not yet have been assigned by WSIB Reminder when you are changing insurance 1 from OHIP to WCB please e2. Ajax Registrations please inform patient to contact Business Office during office hours SUBS INIT n a Leave blank if data exists here please linefeed out SUBS REL n a Leave blank if data exists here please linefeed out S I N required for WCB patients and those patients with insurance coverage entered as 123 456 789 RELIGION enter the mnemonic as on the dictionary look up combined with the Affiliation the first 2 characters represent the religion eg AN Anglican not a required entry for pre registration or registration AJAX always fill in religion field only chose those religions that are recorded as other for affiliations eg ANOTH Anglican Other AFFILIATION n a leave blank EMPLOYER some employers have been entered check lookup using the F9 key Entries such as CHILD and UNEMPLOYED and DECLINED are available if an employer is entered that does not exist on the current list all information re address and phone must be entered Note if you have to enter certain employers frequently ask your B AR rep or site Key User to set up the employer in this dictionary PT OCCUPATION free format entry may be used to indicate employed unemployed NEXT OF KIN enter the name in standard format If the address is the same as the patient enter SP and the address and phone number will default in otherwise enter the data as requested at the Relation prompt a list of mnemo
3. YOU have the ability to update the patient s name on the database REG CAT REGISTRATION CATEGORY enter the appropriate REG CAT press F9 look up key to view read the descriptions carefully to choose the correct one ACCT NUMBER defaults in an automatically assigned number or NEW will appear if you are registering a pre registered patient and the account number stack is the same for both categories you will see the pre assigned number default into this field BIRTHDATE enter in standard format DD MM YY itis not necessary to enter slashes but 2 digits must be entered for day and month Jan 5 1965 is entered 050165 shown as 05 01 65 for some older patients it will be necessary to enter the format DDMMYYYY without the slashes eg 01011897 AGE calculates from date of birth and defaults in if no date of birth is known please enter an approximate age SEX enter M F or U MAIDEN OTHER NAME enter in standard format as patient may already have records under a former name Multiple maiden other names can be entered Do not use this field for reasons other than the maiden other name MOTHER S FIRST NAME not frequently used useful for people with common names e g Mary Smith two may have the same date of birth but not likely the same mother s name or babies with same last name and sex etc Defaults in if you have already identified the patient by U or HCN and information had been previou
4. TTEND PHY must be entered using a mnemonic from the dictionary F9 atthis prompt enter the doctor or therapist or group responsible for this patient therapist mnemonics begin with Z followed by the first 3 letters of the therapist s group s last name in the case of 2 identical surnames the first initial of the first name has been added To view this list enter Z at the prompt then press F9 Note At any doctor prompt if you enter three characters of surname then X and press the look up key you will be able to see the phone number and some other information for the doctors providers whose surname starts with the letters you have entered eg enter as SMI X then press the look up key FAMILY PHY also entered as mnemonic see F9 not a required entry Enter the mnemonic if you know it or enter 2 3 characters of their surname and do a look up and select the name if it is shown If the name is not on the dictionary enter the surname initial and town city if Known in free format e g CASEY B UXBRIDGE If the patient does not have a family physician or does not know the name of the family physician do not enter eg NONE or SCARBORO or LIST GIVEN eg entries at this field generate copies to reports in other modules If you see an entry preceded with a delete or correct It used to indicate that the doctor was not on staff at OGH OTHER PHYS for entry of a consultant or other attending physician
5. USER S MANUAL THE FIELDS IN OUTPATIENT REGISTRATION most are also seen in the Inpatient registration routine also Revision date NOVEMBER 2004 PRE REGISTRATION REGISTRATION Recurring Clinic ER Surg Day Care For all patients there are 6 screens of information required for either pre registration or registration These screens and fields will be explained individually Some registration types may also have Customer Defined Screens CDSs with hospital or location specific questions Some fields are required and others are optional entries are dictionary driven requiring a mnemonic to be entered and others are free format allowing more descriptive entry are optional at pre registration but required at the time of registration have on line assistance where you can press the docum key to view without having to refer to this manual The computer does not allow advancement past required fields but provides assistance through dictionary look up where mnemonics are required PAGE SCREEN 1 Registration Summary PATIENT the key field in patient registration For further information on finding the patient if they already have a record on file at your facility or another facility in Lakeridge Health see the Drawer within the MANUALS Registration Info Procedures Cabinet titled REG N SEARCHES FINDING PTS then gt Picking the Lakeridge patient There are various ways to find the patient but positive ide
6. any doctors looking after patient should be entered here as well so that the patient record is available to them in the PCI module nota required field REASON FOR VISIT free format entry enter the medical surgical reason why the patient is here MEDICAL ALERTS ALLERGIES these are 15 character free format fields There are two such fields for Medical Alerts and four fields for Allergies AJAX registration staff are to just enter yes or no if these fields are not already with recorded entries Please do not remove any existing entries or refer to your key user if you have any questions These fields are shared with the other hospitals in Durham Region and entries such as PALLIATIVE CARE and TT GUSTO 10 11 97 may have special significance in patient care Universal Precautions are in place throughout Lakeridge Health Corporation do not record text related to HIV AIDS etc The Allergy Fields will print on most Face Sheets and the Emerg form If the patient has a LATEX allergy Latex should always be entered in one of the fields If the patient has multiple drug allergies and all cannot be entered in the existing allergy fields Multiple Drugs should be entered in one field This will promote care givers to question the patient directly or refer to a complete list through another chart source Note if the face sheet for the pts visit was printed PRIOR to additional Alerts and Allergies being entered remember that the fa
7. ause the data to default in for age 18 and under it is the custodial parent SNOK or it could be the Children s Aid or Family Services for Foster Children it is the Children s Aid Depending upon the circumstances the name of the Power of Attorney may be the name seen in this field B AR statements are sent to the name shown here this is why we are to show the name of the person responsible for payment of the account It is NOT the name of the person who holds Insurance 2 covering semi You will be able to specify the holder of Ins 2 when completing fields in Guarantor s Employer Note Do not change the guarantor name and or address by entering SP at the name prompt if there is data shown in the Guarantor Employer fields unless you know that this is the patient s guarantor Instead just linefeed the name field then enter the revised name Otherwise the patient s employer and not the employer of the person who holds the secondary insurance will be entered into the Guarantor Employer section If an address change is needed then YES you can enter SP in the address field GUARANTOR S EMPLOYER See Standard 6 for more details although this field must be collected for INPTS for OUTPT registration this field is less applicable collect if possible usually patient s employer will default from previous registration for adults or it will be entered if you enter SP for same as patient
8. ce sheet will needed to be reprinted or the additions noted on that page and initialed as the caregivers are referring to this information for the current visit LOCATION entered as a mnemonic see F9 very important for statistics In a pre registration the next prompt will be SERVICE DATE please enter the expected date of the first visit if unknown generally the convention has been to enter 25 12 of the current year unless the month is December and visit is not expected in that month or 31 03 of next fiscal year if visit is not expected in the current fiscal year RESERVATION TAKEN AT TIME will default in as the current date and time COMMENT a free format field for extra information may be used to record medications or a prompt to registration staff about checking particular information when the patient arrives In a registration the next prompt will be DATE TIME these default in as the current date and time but may be linefeed out to enter a previous date or time eg needed for areas doing registration after pt arrival or for newborns to show date time of birth future times and dates may not be entered COMMENT as above
9. e city prompt and the city province postal code AND residence code will default to those fields PROVINCE enter the 2 digit code according to Canada Post see standard formats POSTAL CODE as per standard format if patient is a resident of Ontario and P C unknown enter 5 if the P C is not known and pt NOT from ONtario enter i HOME PH enter the patients home phone number with area code as NNNNNNNNNN It will automatically display as NNN NNN NNNN As of 26 Jun 01 the standard format is for the area code to be included for ALL phone numbers When registering patients if you notice a phone number without an area code please correct the number by adding the area code RESIDENCE CODE enter the 4 digit code from the Residency Code Manual For details see Standard 2 MARITAL STATUS enter the mnemonic see table F9 may use U unknown only when applicable Note at some facilities has been designated as not required LANGUAGE enter the mnemonic see table F9 HCN Health Care Number will only accept valid HCN s if a version code is on the card it follows the number separated by a dash e g 1231231231 Q if HCN not available and old 8 digit OHIP shown delete that number LHC MOH Health Care Number Release forms are used whenever there is a problem with a HCN eg invalid version code HCN not available etc and in Emerg the pt is given information with a phone number to call
10. maiden other name field At this point the cursor appears beside the Insurance data on the screen It is meant at this time for the user to confirm the data displayed on the registration summary eg Patient address Employer Next of Kin Person to Notify Guarantor Guarantor s Employer and list of Insurances Once the user presses the return key a menu box appears listing the screens and their content in order From the summary screen the user can decide which fields need entry or editing and proceed directly to that screen NOTE There will always be required data entry on screen 6 prior to F iling Remember to check for correct spelling of all demographic information listed previously as well as all new information you enter on a patient PAGE SCREEN 2 DEMOGRAPHIC DATA includes all data formerly entered on page 1 and 2 of the registration screens STREET enter as much information as possible on the FIRST line free format Many report formats do not refer to the second street field Do not use the sign eg RR 1 as the sign causes the embosser to stop printing at that character Follow standard format cheat sheet note for proper format of address for apartments it is entered as the apartment number street number eg Apt 121 35 Simcoe St S would be entered as 121 35 Simcoe St S For Nursing Home CITY if from outside Canada also enter the state and or country TIP if you know the postal code enter it at th
11. nics is available using F9 a CDS screen may be attached for additional contact number PERSON TO NOTIFY if same as Next of Kin leave blank and it will be assumed that PTIN SNOK see Registration Standards 1 for further details if this information is different enter the data at each prompt as required a second person is usually collected for inpatients only but once collected is stored in demo recall a CDS screen may be attached for additional contact number PAGE SCREEN 3 INSURANCES amp GUARANTOR INSURANCE 1 usually OHIP use F9 to view the list of all insurances if the patient is from another province or outside Canada Other Canadian provinces start with PP and Federal plans such as RCMP and Armed Forces start with FG Federal Government Note specific detailed notes re non residents out of country can be found in this MOX Library CABINET NAME ACCESS OWNER Non res amp Out of country READ ONLY VELLA LISA V 2 refers to extra insurance for semi private or private coverage Most general insurances start with letters Gl 3 n a for recurring but do not erase existing info Note when you are changing insurance 1 from OHIP to WCB please enter N at the question Retain policy holder information from OHIP so that you won t need to remove the HCN which defaults to the WCB Policy field GUARANTOR the guarantor is always the patient if 19 years of age or over entering SP will c
12. nter N at the question Retain policy holder information from OHIP so that you won t need to remove the HCN which defaults to the WCB Policy field If secondary insurances are entered please enter relevant data as requested in the pop up screen seen after you press return at the Query screen for that particular insurance This is seen for GS Green Shield QUERY SCREEN ZA00010 and shows FORMAT 000000 00 or ABC 000000000 00 EMPLOYER FOR THIS COVERAGE GOES UNDER GUARANTOR EMPLOYER PEREGRINE EMPLOYEES WERE GM GET NEW POLICY With the exception of Liberty Health all policy numbers are entered at the policy number line group Sl policy etc Liberty Health must have the policy number on the policy line and the group number entered at Company number PAGE SCREEN 5 ACCIDENT OCCUR INFORMATION This screen is infrequently used often bypassed unless required by a specific registration location ADMISSION SOURCE use the F9 key to view the list of mnemonics ACCIDENT OCCURRENCE use the F9 key to view the list of mnemonics The remainder of the fields on this page are free format entry and are used by the hospital mainly for WCB patients These may be filled in or left blank as appropriate PAGE SCREEN 6 DOCTOR amp LOCATION INFORMATION PRIM CARE PHYS do not enter a physician mnemonic here this field used in US for managed care and not currently used by the Durham Region hospitals A
13. ntification is faster if you have either the Unit unique number or the HCN for the patient enter U followed by the 8 digit unit CPI UNIQUE number if known at LHO this can be a 6 or 8 digit unit number Leading zeros do not need to be entered enter followed by the Ontario Health Card number if Known If there is a version code put a hyphen after the HCN then the version code eg 1234567890 XX Note this is becoming the preferred method for identifying patients but keep in mind that if the patient isn t found by the 10 digit root HCN the patient may still be in the MRI database eg with old OHIP enter the telephone number T 9055791111 this will display all the patients registered with that phone number There may be several family members listed please choose the correct one if there If you have neither the Unit or HCN at this prompt enter the patient s name in standard format LASTNAME FIRSTNAME described on page about standard formats alist of recent accounts at the hospital will appear on the screen for any patient s with this name Also any existing pre registration for the patient will appear with an option to select those accounts Please check locations carefully so as not to select a pre registration for another department If no pre registration exists or is chosen press return When the cursor is at the name prompt verify the proper spelling If this is the most recent visit for the patient
14. sly collected Is automatically added when newborns are registered in the Newborn Registration routine UNIT For those patients not already identified by U or HCN at this prompt the computer will automatically do an MRI search for an existing record of this patient 8 levels of search will occur searching all records with similar names sex date of birth range and maiden name these records are listed with an option to view more information before choosing a record if no record is chosen New defaults in at this prompt and a NEW unit number will be assigned further demographic information will be required if a record is chosen the existing unit defaults in with all existing information and you must then proceed to verify or update this data if patient ID fields eg name sex dob do not match the existing data in Medical records the user is prompted to U pdate i e update the pt information to what you have entered for the current registration you are doing C opy i e accept the pt information as it had been collected on the patient s previous registration or S earch again takes your cursor back to the Unit number prompt so that you can search further Guide to using the U or C option use U to update if the name you ve entered will improve the name use C if what was already on file for the patient was better If you have used U the patient s former name will automatically be added to the
Download Pdf Manuals
Related Search