Best Practices for Data Capture by Data Attribute

The following best practices are based on content developed by the National Association of Healthcare Access Management.

Patient Name data may be stored in the following five fields:

• First name/given name: this should be the patient’s legal name as it appears on their insurance card.
• Last name/surname: Generational titles such as Jr, Sr, III are considered part of the last name, and should be included in this field.
• Middle name or initial
• Suffix – Should be used to indicate educational degrees and accreditation. Common suffixes include MD, DO, CRNP, PhD.
• Prefix - Should be used for professional or religious titles or honorifics such as: Doctor, Sister, Father, Professor (could routinely be entered using typical 2-character designations – Dr, Sr, Fr). It is not necessary to collect common prefixes such as Mr, Mrs, Ms, and Miss.

Dos and Don'ts for recording patient name

DO use the patient’s government-issued photo ID to collect the patient’s Name, or use the patient’s insurance card to record the legal name.

DO ask the patient for their middle name and record at least his/her middle initial if they have one.

When a patient’s first name is an initial DO capture just the initial in the first name field and use the Middle name field for a full name.

DO capture the patient’s preferred name, if she/he has one.

DO include a suffix, such as Sr, Jr, II, etc. in the Last Name field.

Do capture punctuation commonly used in names such as hyphens (-) and apostrophes (’).

If an existing patient gives a name that does not match an existing record DO ask the patient: “Are there any former legal names or past or present nicknames for you?”

If the spelling of a patient’s name on their ID does not match their insurance card, DO ask the patient to update/correct the spelling of their name with their insurance company in order to ensure payment for services.

DO NOT capture the patient’s preferred name in the First Name field, but in a field for preferred name if one exists.

DO NOT include a suffix, such as MD, DO, RN, etc. in the Last Name field.

DOB should be recorded for all patients, even if the patient does not know their DOB.

Dos and Don’ts for recording DOB

DO record DOB in the following format: MM-DD-YYYY

If the full DOB is unknown or the patient is unresponsive, and a representative is not immediately available, DO record the DOB in a standard format, such as 01-01-1880. DO be sure to update the record as soon as the DOB is available.

If only the year is known, DO record the month and day in a standard format, such as 01-01-yyyy (year provided by patient).

If the patient is a twin, DO record the hour, minute, or second for DOB, if known and your system allows. Work with your supervisor to establish and maintain a consistent, standardized method to record multiple births, including birth order.

Generally, address fields should follow the United States Postal Service (USPS) – Postal Addressing Standards:

Address Line 1: House Number and Street Name
Address Line 2: Suite #, Apartment #, etc.
City, State and ZIP+4 Code (Note: city, state and zip in separate fields)

Dos and Don’ts for Recording Address

DO use the US Postal Service standard abbreviations for street suffix. Commonly used address abbreviations include the following:

DO verify the patient’s address using his/her government issued ID or a utility bill or other mailing.

Do use a hyphen in the ZIP code field when using the ZIP+4.

DO record and maintain historical addresses.

If an existing patient provides an address that does not match an existing record, DO ask the patient: “What are your former addresses?”

If a patient is homeless, DO use the practice’s billing address for the patient’s address.

DO Record all temporary, seasonal, and confidential addresses where applicable.

DO use the USPS format for capturing international addresses. The bottom line of the address should show only the COUNTRY name, written in full (no abbreviations) and preferably in capital letters.

DO NOT use any punctuation in the street or city fields.

Generally, enter a patient’s phone number according to the North American Numbering Plan (NANP). The number should be 10 digits including the patient’s area code (XXX) XXX-XXXX.

Dos and Don’ts for Recording Phone Number

DO ask patients if their phone number is a home, office, or cell/mobile number and indicate for each number if it is primary or secondary. DO record the phone number in the corresponding phone type field in your system.

For emergency contact information, DO include the phone type and primary and secondary fields, as well as the full name and address.

DO ask patients to verify their phone number during every patient encounter.

For international phone numbers, DO use a dropdown for Country name and choose the appropriate country.

If a patient is unable to provide a primary phone number, DO enter 111-111-1111 to indicate the phone number is unknown.

If an existing patient provides a phone number that does not match an existing record, DO ask the patient: “Are there any phone numbers you once had but no longer use or no longer have?

DO NOT leave the phone number field blank.

Sex – a person’s biological status referring to their genetic, hormonal, anatomical, and psychological characteristics of male, female, or intersex.

Gender – a person’s attitudes, feelings, and behaviors associated with their biological sex.

Gender Identity – a person’s basic sense of being male, female, or other gender (for example, transgender or gender queer). This may be the same or different from their sex assigned at birth.

Dos and Don’ts for Recording Sex and Gender

DO record both Sex and Gender in separate fields.

DO check identification for patient’s sex.

In the absence of government identification or physician documentation, DO ask the patient their sex at birth.

If a patient is not available, and their identification is also unavailable, DO record the sex as unknown.

DO record the patient’s sex as Male (M) or Female (F), if the sex is known.

DON'T assume the patient’s sex based on visual appearance.