Standards for general practices

Core module

Criterion C6.1 – Patient identification

        1. Criterion C6.1 – Patient identification

Indicator


C6.1 A Our practice uses a minimum of three approved patient identifiers to correctly identify patients and their clinical information.

Why this is important

Verifying a patient’s identity helps to maintain patient safety and confidentiality. Failure to correctly identify a patient can have serious, potentially life-threatening consequences for the patient.

Using three approved patient identifiers reduces the risk of misidentifying patients and ensures that practitioners have the correct patient health record for each consultation. Rand Corporation, a nonprofit research organisation, provides further information about the importance of correctly identifying patients.

Meeting this Criterion

Correct patient identification is necessary when:

  • a patient makes an appointment
  • a patient presents to the practice for their appointment
  • you communicate with a patient over the telephone or electronically
  • a patient telephones asking for a repeat of a prescription
  • a patient sees more than one practitioner during a visit
  • a patient record is accessed
  • you collect and manage information (eg scanned documents, X-rays) about a patient.

Approved patient identifiers are items of information that are accepted for use to identify a patient. They include the following patient details:

  • Name (family and given names together are one identifier)
  • Date of birth
  • Gender (as identified by the patient)
  • Address
  • Patient health record number where it exists
  • Individual Healthcare Identifier

A patient’s Medicare number is not an approved patient identifier, as some Australian residents and visitors do not have a Medicare number2 and others may share numbers if they belong to the same family.

Asking for patient identifiers

When asking for patient identifiers, practice team members must ask the patient to state at least three identifiers (eg their full name, date of birth, and address), while remaining mindful of privacy and confidentiality issues. Practice staff must ask the patient for the information, rather than provide the identifying information and then ask the patient to confirm the information.

A patient could supply government-issued photographic documentation (eg their drivers licence or passport) to provide information for your records and to subsequently provide one or more identifiers.

When a patient is well known to the practice team, it may appear unnecessary or illogical to ask for identifiers every time they attend or call the practice. However, it is common for practices to have patients with identical or similar names, or dates of birth, and to therefore mismatch patients and patient health records. Some practices overcome this by routinely asking patients to verify their address and other particulars each time they attend. This also helps the practice to maintain accurate contact details for each patient.

Patients who wish to remain anonymous

Wherever it is lawful and practicable, patients must be able to remain anonymous when receiving care from your practice.27 Patients may choose to receive services anonymously if, for example, sensitive issues arise or they feel they may be at risk, such as in domestic violence situations or difficult relationships. In these circumstances, the use of an alias or ‘disguised identity’ may be the most appropriate approach.

Meeting each Indicator

C6.1 A Our practice uses a minimum of three approved patient identifiers to correctly identify patients and their clinical information.

You must:

  • use a minimum of three approved patient identifiers to confirm a patient’s identity each time they attend or call the practice.

You could:

  • keep a prompt sheet at reception to remind reception staff to ask for approved patient identifiers
  • explain to patients the reasons for identifying them at each visit (eg safety reasons, keeping accurate patient details), particularly if you have a small practice or have patients well known to the practice team members
  • maintain a policy of acknowledging, recording and implementing the names and pronouns used by each patient.

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