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(Continued from page 75)
security number, date of birth, place of birth, address, phone number, handedness, mother's maiden name, past medical-surgical history, medications, allergies, children with dates of birth, insurance company and number, physicians seen by dates, physical summaries per visit, summary of office visit to be less than 50 words, list of prescription refills, dates of hospitalization, dates of emergency room visits, some ancillary tests, new diagnosis, new surgeries, ICDM codes, CPT codes, and health traits such as smoking, family history, alcohol use, careers, employers, etc. It will be the responsibility of the computing department to develop a program to manage this data. The information should be managed in such a way that if a patient presents to your office, your office has the ability to query the data base and print up the patient profile. It may also list medications separately, hospitalizations separately, E.R. visits separately or a combination of data as the consortium believes will be beneficial to all.
Each time that a patient comes to a physician's office, the office makes the inquiry into the database. The patient's data record consists of a prefix of three spaces, each space will be alphanumeric, followed by two initials, followed by the social security number, followed by the first and second letter of the mother's maiden name. When the inquiring office requests the data, they will need the patient's initials, social security number, and first two letters of the patient's mother's maiden name. If the patient does not exist in the database, it will be that office's responsibility to enter all of the information. Therefore, there will be the need of a general intake sheet to be used by all offices. Any inquiries into the database are recorded. If there is an inquiry without input such as updated information within five days of the inquiry, or as many days as is determined, then there will be an investigation into that inquiry. Each office has an individual access code and password to either view or enter new information. No office will be able to change any old information. Old information can only be changed through the data base administrators and a physician's office. When a new patient is entered, the database will assign the three alphanumeric prefix. This way the patient can access their own data by knowing their prefix. The patients will not have the ability to change their data. The hospital and surgical center admissions office may also be able to obtain data only if they agree to update it immediately upon conclusion of their encounter. This may consist of the emergency room or hospital or surgical center admission date, diagnosis, and medications dispensed. I do not know how to deal with a patient that presents incapacitated and, therefore, will not be able to give the two digits of their mother's maiden name. This may be able to be obtained via a relative or by knowing the patient's prefix, which will be kept on file at the doctor's office, emergency personnel would be able to obtain this and, therefore, data that way. At the end of each doctor's office visit, the record (Continued on page 77)
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