Registration of patients in hospital – Policy and Procedure

Registration is a process by which a patient’s name and identity are enrolled into the records of the hospital. This is required in order to provide services of the hospital to the patient and to keep a track of various services that are availed by each patient. This is also the first step to generate a medical record of the patient in which all medical details of the patient are documented.

Registration is done with the following objectives
1. To collect basic details of patient related to identity, contacts and demography
2. To create a unique identification number for each and every patient
3. To enter patient’s name in the hospital’s system
4. To generate a record of the patient for documenting further processes related to him/her

To ensure that registration process is carried out smoothly and its objectives are met, a hospital must have a well-defined and documented policy and procedure for carrying out registration of patients. The guidelines given below can help in formulating a relevant policy and procedure for registration.

Who should be registered

All first time patient to the hospital who wants to avail the services of the hospital must be registered. This includes patients who come to OPD or Emergency or transferred in from another hospital.

However, in following situations registration shall not be done
1. If the patient is already registered with the hospital and registration details in available
2. If the healthcare service required by the patient is not available in the hospital
3. If the patient unknown to the hospital is brought in dead condition. In this case brought in dead policy must be followed

When shall the registration be done

Registration shall be done as a first step before any healthcare service is provided to the hospital. However, in a medical emergency situation where care needs to be provided urgently, registration can be done simultaneously or later as per the situation. Such cases shall be handled in the hospital’s emergency department and urgency shall be determined based on Triage process

How shall the registration be done

Registration shall be done by asking the patient to fill up the registration form, in which basic details of the patient is required to be filled. Help shall be provided to the needy patient in filling up the registration form.
· The form shall be signed by the patient (or thumb impression taken).
· The details from registration form shall be entered into the registration module of HIS. Once the information is saved, the computer will generate a unique identification number (UIN).
· This UIN along with name, address and date of birth of patient shall be printed, signed and handed over to the patient.
· Applicable fee of registration must be collected from the patient for which the receipt must be issued.
· The registration form that was filled and signed by the patient must be stored securely in the registration file.
· In the case of a minor patient, the parent/guardian of the patient must sign on the registration form

Information to be collected at the time of registration

Following information must be collected from the patient through registration form
· Name
· Date of Birth
· Gender
· Name of guardian (in case the patient is a minor)
· Relationship with the patient
· Address
· Contact number
· Email address
· Occupation
· Health Insurance details (If applicable)
· Referring doctor’s name (if applicable)
· For contacting during emergency
     o Name of person
     o Relationship
     o Contact number

Information to be provided to a patient getting registered

Patient getting registered must be informed that this is a one-time registration and will remain valid for the lifetime. He/she should be told about the unique identification number and that it can be used to access the hospital’s services in future. He/she shall also be informed about how his/her registration details can be retrieved other than UIN.

Registering an unidentified patient

In case an identified patient is brought to the hospital (such as an unconscious patient brought by strangers), an incomplete registration shall be done by entering the name as ‘Unidentified’ followed by a serial number. For example, first unidentified patient shall be written as ‘unidentified-1’ next one as ‘unidentified-2’ and so on. A UIN will still be generated for that patient and healthcare services can be provided. The incomplete registration shall be completed as soon as identification details of the patient become available.

Retrieving the details of a registered patient

UIN can be used for retrieving the details of the patient in any department of the hospital. However, if the patient has forgotten his/her UIN, the same can be retrieved from the HIS, by entering other details of the patient such as name, date of birth, contact number etc.

Confidentiality of information

The information collected at the time of registration is private information of the patient and shall be kept confidential. This is an important part of fulfilling patients' rights. The information shall only be used for the purpose of providing healthcare services. The access of the patients’ information will only be given to specific departments and staff. This data shall not be revealed to anyone from outside of the hospital. In certain circumstances, such as legal authorities requesting for information, the facility head (or a designated authority) shall take the decision.

Modifications in details collected during registration

Once the registration is completed, any modification in the information collected shall generally not be done. However, in certain cases, such as spelling mistake in the name, or a correction required for insurance claim processing, the facility head (or a designated authority) shall take a decision on a case to case basis, after assessing the evidence for modifying information. If modifications are made, a track of all modifications shall be maintained.

Registration record

As the registration is for the lifetime the registration details shall be saved and stored for the lifetime in HIS. The registration form filled and signed by patient shall be stored for at least one year after which it can be discarded through shredding.