Welcome to Nuance Transcription Services Patient Demographics Training!

The
purpose of this training session is to educate our team on patient demographics and
the important role demographics play in a patient’s medical record.

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Patient demographic information is one of the most important parts of a patient’s
medical report. Patient demographic information allows healthcare providers to
identify the patient.

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In a patient’s report, demographics are dictated by the author of the report. It
typically consists of the patient’s first and last name, medical record or account
number, date of birth, social security number, gender, and visit date.

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Depending on your assigned account, transcription platform, or dictator, the
demographic information may auto-populate. If it does not, you may be able to
search for and select the patient demographic information from a list using the
dictated demographic information provided by the author at the beginning of the
report.

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The medical record number is assigned by a facility for each individual patient. Once
a patient has been assigned a medical record number, that number will never
change…no matter how many times they visit the facility. This is a unique identifier
for the patient.

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The account number or visit ID will be different every time a patient visits a facility.
This number is attached to all services rendered for a particular visit, so if a patient
comes to a facility and has a visit, lab work, and x-rays, all of those would be attached
to the same account number or visit ID. A patient could have many visit IDs at a
facility throughout their lifetime.

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To assist with selecting the correct medical record number or account number/visit
ID, evaluate the facility’s numbering format. Is one longer than the other? Does one
of the numbers contain only digits but the other a combination of letters and
numbers? It is very easy to transpose numbers or enter the wrong number. Some
facilities have the physicians enter the medical record number while others enter the
account number or visit number. If the physician enters the account number instead
of the medical record number or vice versa, it could cause the wrong patient to auto-
populate.

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Often, when searching to confirm patient demographics, you will find the most recent
patient visit appears at the top of the patient demographics search window and is
automatically selected. However, this is not always the correct visit and must be
verified against what is dictated. There may be times when a report is not dictated
until a long time after the visit or a future visit may have auto-populated. Be sure to
listen closely to the dictated date of service. Additionally, if a patient is an inpatient
and has a procedure done, be sure the visit selected includes the date of service
timeframe. For instance, if a procedure was done on May 12, 2015, but the visit
selected has an admission date of May 20, 2015, that would not be the correct visit
or the date of service was dictated incorrectly.

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To verify the correct patient has been selected for the report you are working, listen
closely to the dictation. Does the name in the demographics information match what
is being dictated? Does the medical record number match? Does the date of birth
match the age of the patient that is dictated? Is the patient the correct gender? Is
the dictator listed as part of the patient’s care team? All of these questions can assist
in ensuring that the correct patient has been auto-populated or selected.

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To verify the date of service, double-check to be sure that the date of service falls
within the date range for the visit ID selected.

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To assist with selecting the correct worktype, verify that the worktype is used by the
facility.

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Even if the demographic information prepopulates on the report, it is extremely
important to verify all demographic information so that the correct visit is attached to
the correct patient. Once the report is uploaded into the electronic health record
(EHR), it is immediately visible and accessible by healthcare professionals who are
relying on the information to be accurate. If patient demographic information,
provider, or worktype information is incorrect, the clinical information in the
document will not import into the EHR in a timely fashion, thus impacting patient
care and safety. There are situations in which wrong demographic information can
result in clinical information being associated with the wrong patient, creating a
potentially dangerous situation for a patient. Never assume that the patient
information was properly keyed in by the dictator. Always confirm the prepopulated
demographic information with what is dictated. A document sent to the client with
incorrect patient demographic information will be considered a HIPAA incident and
critical patient safety error with penalties as such.

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Pay careful attention to patient demographics and directions, such as carbon copies,
worktypes, etc., that are dictated usually in the beginning of each report. Double-
check the patient’s age with the age and/or DOB in the header. Use the age
determination cheat sheet to avoid sound-alike numbers with ages. Listen to all
demographic information twice to reduce demographic errors.

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To help reduce demographic errors:
• Listen to the first 10-15 seconds (the demographic info) of the report twice.
• If all the demographic information has been auto-populated, keep your hands off
the keyboard and just listen. Verify that all the data is correct.
• If there are several fields in the demographics that you had to manually fill in on
the first listen, listen the second time keeping your hands off the keyboard. Verify
that you have correctly entered all the data.
• When in doubt, leave it out. Flag it, following the pending rules for your account.

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Choosing the wrong dictator can also result in a delay in the signing and release of a
report, affecting patient care. If the report is an edited report, choosing the wrong
dictator can cause the voice model to be affected where the draft reports that come
in for future reports have many errors. This in turn can cause a delay in completion of
the reports due to the MLS having to spend more time on the report.

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Adding incorrect carbon copies can result in possible HIPAA violations and delay in
patient care. Missed carbon copies can also delay patient care. Carbon copies can be
dictated in any part of the report. Be sure to listen closely at the beginning but also
at the very end of the report. Sometimes MLS get to the end of the dictation of the
actual report and stop listening as quite often the dictator is just repeating some of
the same patient demographics as before or thanking the MLS for completing the
report, but sometimes carbon copies are dictated at the end as well. Do not be in a
rush to get to the next report and miss a dictated carbon copy.

Another tip to avoid missing carbon copies is to add them as soon as they are
dictated, particularly if they are dictated at the beginning or within the report.

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To locate a carbon copy, if the physician works for the hospital, try searching your
platform pick list. If the physician cannot be located, next try the hospital website.
Most hospitals have a “find a doctor” search that is very user friendly where you can
search a variety of ways, including just the first name. If a carbon copy is requested
for a physician who is not part of the hospital or if you are still unable to locate the
correct physician, then use the WebMD Find A Doctor page. This again allows you to
search a variety of ways and is very helpful in finding doctors.

If there is any doubt that the correct carbon copy has been located, do not select
one. Follow your account’s pending instructions for unknown carbon copies. Never
guess!

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In the patient demographics screen, depending on your platform and/or worktype, there
may be several different provider fields. These could include the Dictator or Speaker, the
Cosigner or Signing Clinician, the Attending and Referring. Some of these fields might always
remain empty due to the facility not using them. Others might be empty but must be filled
in, such as the Signing Clinician field. Refer to your account specifics for more details.
The Speaker or Dictator should be the provider who is dictating the report. Be sure to pay
attention when the dictator states his or her name as sometimes there is a typo made when
they enter their dictator number or perhaps they are using another physician’s dictator
number for some reason. If the dictator number is not correct, a different dictator or
speaker will autopopulate. This should be changed to the correct speaker to avoid problems
as mentioned earlier in this session.
The Signing Clinician or cosigner is usually used for dictators who do not have signing
privileges. However, some facilities have the dictator’s name listed in that field as well, and
some facilities leave the Signing Clinician field blank if the dictator can sign their own reports.
The Attending physician field could also be blank, have the dictator’s name listed, or have a
different physician’s name listed. If there is a different physician listed, that would mean that
the attending physician is in charge of the patient’s care during this particular visit, but the
dictator is taking care of this part of the patient’s care. This might be a specialist that was
called in to consult or a physician who is filling in for the attending due to vacation or the
dictator is the one on call.
The referring physician is the one who referred the patient to the facility for this visit. Again,
this field may be blank or filled in, depending on the facility and/or platform.
There may be other fields listing different physicians as well. Always double-check your
account specifics to see which fields need to be filled in.

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Demographics are the elements used to identify and tie the patient to the medical
record, including name, birthdate, date of service, account number, visit number. It is
critically important to always verify the patient information dictated to the
information automatically populated within the report you are editing or transcribing.
Patients and healthcare professionals are relying on the accuracy of information
provided in our medical reports. If patient demographic information, provider, or
worktype information is incorrect, the clinical information in the document will not
import into the electronic health record in a timely fashion, thus impacting patient
care and safety, as well as potentially resulting in clinical information being associated
with the wrong patient, creating a potentially dangerous situation for a patient. IT
OUR MISSION TO BE THE BEST, REAL-TIME CONDUIT FOR PATIENT CARE AND
PATIENT SAFETY. You make the difference.

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Thank you for completing the Demographics Training Module. If you have any
questions regarding this training module, please do not hesitate to contact the
Nuance Transcription Services Training Department at NTS_Training@Nuance.com.

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