Patient Identification and Demographics

Patient Identification & Demographics

• Purpose

  Proper patient identification and demographic recording are essential to ensure data integrity, accurate report association, and compliance with medical documentation and safety standards. Incorrect identification can lead to diagnostic and legal errors.

• Essential Identification Fields
  • Full Name: Enter the patient’s legal name as per hospital records (avoid nicknames or abbreviations).
  • Unique Patient ID / MRN: Hospital-generated identifier that links all records across imaging, lab, and clinical systems.
  • Date of Birth (DOB): Format as DD-MM-YYYY; use to auto-calculate and display age in years and months.
  • Age / Sex: Display automatically or manually input; crucial for reference range interpretation in sonography (e.g., fetal or prostate measurements).
  • Contact Information: Include mobile number, address, or email (for communication or digital report sharing, following privacy policy).
  • National / Government ID (optional): Useful for long-term or multi-center data tracking when permitted (e.g., Aadhaar, SSN).
• Demographic Details
  • Address & Region: Record for epidemiological tracking, correspondence, and report delivery when needed.
  • Ethnicity / Race (optional): May be relevant in specific studies or fetal growth references (e.g., FMF ethnicity-based percentile charts).
  • Occupation: Optional; can assist in correlating occupational exposures (e.g., vibration, chemical exposure) with findings.
  • Marital / Obstetric Status (for OB/GYN cases): G, P, L, A (Gravida, Para, Live, Abortion) – important for pregnancy-related studies.
• Administrative & Visit Information
  • Hospital / Clinic Name: Auto-filled based on logged-in facility or preset configuration.
  • Department / Unit: e.g., Radiology, Obstetrics, Cardiology, Vascular Lab.
  • Referring Physician: Include name and department to enable follow-up communication and feedback.
  • Date & Time of Registration: Auto-captured to align with examination logs and DICOM headers.
  • Exam Number / Accession ID: Generated per visit for cross-referencing with PACS and EMR systems.
• Clinical Information Summary

  This section links demographics to the clinical context by recording chief complaint, relevant medical/surgical history, current medications, and previous imaging results. These data ensure correct report interpretation and continuity of care.

• Data Entry Standards
  • Use consistent formats for dates and capitalization.
  • Avoid free-text duplication of names—prefer structured input fields.
  • Ensure automatic field validation (e.g., DOB cannot be future-dated).
  • Restrict unauthorized editing of ID fields after initial registration to prevent mismatches.
• Privacy & Data Protection
  • Follow data privacy regulations (HIPAA, GDPR, or national guidelines).
  • Mask sensitive identifiers on public displays or when exporting teaching images.
  • Implement role-based access control (operator vs. radiologist vs. admin).
  • Encrypt patient demographic data in transmission and storage when integrated with cloud systems.
• Integration with Report System

  Demographic fields should auto-populate across the ultrasound report, image headers, and exported PDF. Patient ID, name, age, and exam type must appear on every image and printed page to maintain traceability. Integration with HIS/PACS allows automatic demographic import and prevents manual errors.

• Final Identification Checklist
  1. Verify name and MRN match the referral form or wristband.
  2. Confirm DOB and sex before starting the scan.
  3. Ensure the referring physician and clinical notes are entered.
  4. Confirm demographic fields auto-fill correctly on report and image labels.
  5. Lock demographic fields after verification to maintain audit integrity.
• Optional Enhancements
  • Photo capture or barcode scan of patient ID for rapid verification.
  • AI-based demographic entry validation against hospital EMR records.
  • Custom demographic templates for pediatric, obstetric, or vascular studies.
  • QR-code generation on final reports linking to digital copies or PACS study page.