The Medical Record Number

Why is it so important to include the patient's medical record number in any documentation generated for a hospital chart? Because the medical record number is the one data field which will appear in almost any database relating to the hospital's patient population. This number is used for billing purposes, is a key marker in the hospital census, and also appears in the surgical schedule.

In some situations, the medical record number may be the only way of being sure that you are discussing the patient whose care you are attempting to document. How so?

• Some doctors inadvertently omit the patient's name when dictating reports. Without the patient's name, it becomes pretty hard to identify the patient -- unless you can find the patient's medical record number.

• Some patients have been admitted numerous times to a hospital and, as a result, have been given more than one medical record number. The number you dictate should relate to the hospital admission you are documenting.

• Some doctors mispronounce -- or fail to spell -- the patient's name when dictating reports. As a result, the document can end up in another patient's chart, or get lost in a jungle of hospital documentation.

• Many cities now have large ethnic populations. Searching a database for a patient named "Chan" in San Francisco, "Hernandez" in Los Angeles, or "Schwartz" in New York might reveal hundreds of patients with the same last name. The medical record number may be the only way of finding the correct "Carlos Hernandez," "John Chan," or "Paul Schwartz."

• With an increasingly large number of Asian patients in large cities, it is often difficult to identify which word represents the patient's first, middle, or last name. Names like Boon Hang Ling or Fang Nguyen can easily be transposed to read Ling Hang Boon or Nguyen Fang. Once again, the medical record number serves as a crucial identifying marker.

When you have finished entering numbers into the various datafields (author ID, report type, medical record number) as requested by the digital dictation system, you will be asked to press a certain key in order to begin dictating.

Next: How Have Computers Changed Dictation and Transcription?

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