This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.
By Julie Dooling, MSHI, RHIA, CHDA, FAHIMA, and Robyn Stambaugh, MS, RHIA
Clinical documentation improvement (CDI), a subset of health information management (HIM), is dependent upon accurate and available patient identification. Without accurately identifying our patients and placing data integrity first, we are placing all subsequent documentation and the patient’s health information at risk.
Assigning newborns temporary names at birth is a common practice for hospitals. As a result, a large volume of patients with similar identifiers could potentially result in duplicate records and increase the risk for sentinel events (e.g. circumcision performed on wrong patient).
Due to these patient safety risks, in 2015 The Joint Commission (TJC) recommended discontinuing the use of “Babyboy or Babygirl” as part of the temporary name assignment. This was followed by a January 1st, 2019 compliance date for all Joint Commission-accredited hospitals and critical access hospitals that provide labor and delivery services. They will be required to use a new element of performance under the National Patient Safety Goal (NPSG) 01.01.01.
- The NPSG calls for “at least two patient identifiers when providing care, treatment and services.” One identifier could include distinct naming systems using the mother’s first and last names and the newborn’s gender (“Smith, Judy Girl” or “Smith, Judy Girl A” and “Smith, Judy Girl B” for multiples). Another could be standardized practices for identification such as banding with either a two body-site identification and barcoding.
Many healthcare organizations have been using these best practice naming conventions for some time. Katherine Lusk, MHSM, RHIA, FAHIMA, chief health information management and exchange officer at Children’s Health System of Texas was instrumental in working with the Texas Health Information Management Association (TXHIMA) and the Children’s Hospital Association, advocating for the following standardized naming convention for temporary newborn names.
- Mom’s name: Katie Smith
- Mom’s maiden name: Katie Miller
Baby’s name if she had a girl: Smith, Girl Katie
Baby’s name if she had a boy: Smith, Boy Katie
Baby’s name if she had an undetermined sex: Smith, Baby Katie
If the mom has twins: Smith, Girl A Katie and Smith, Boy B Katie
Additionally, there are challenges that require planning and workarounds:
- If a baby is adopted, the birth mother’s last name will be used in the temporary naming convention until the adoption is finalized and a legal name is given. The legal name may or may not be finalized while the baby is still in the hospital. Changing the name to a legal name should be completed as soon as possible. However, performing this function post-discharge is preferred to avoid any interference and confusion with downstream system processing (for instance, blood bank and automatic medication dispensing systems) while the patient is still in the hospital.
- If a baby is deemed a safe haven baby, a special naming convention should be considered. Jami Woebkenberg, MHIM, RHIA, CPHI, FAHIMA, senior director, HIMS operations at Banner Health, shared the following naming convention to uniquely identify safe haven babies:
- Identify patient by the:
- BABY, followed by the facility abbreviation for the last name,
- “SH”, followed by
- Date (mm/dd/yy format) and
- Time for the first name
- Identify patient by the:
Example: a patient treated at facility XYZ 11:15 a.m. on August 30, 2007 would be
named BABYXYZ, SH083020071115
- Considerations should also be given to how temporary names are accepted or, in some cases, not accepted in various state databases and registries. Haimwattie R. Pariag, RHIA, CHP, CHTS-PW, senior revenue management consultant, mid revenue cycle for Trinity Health shared that some states’ reporting agencies, immunization registries, trauma registries, and any other registries may not accept a temporary name or alphanumeric name, so workarounds must be crafted.