Ahh, the simplest things. You need the patient’s name, date of birth, and social security number if possible. The name is most important. If the name is John Smith or Juan Martinez, the date of birth helps.
I was a brand new spanking EMT and we had a patient in classic CHF — I am talking hypertensive through the roof, bulging jugular veins, filling emesis basins with pinky frothy sputum. We had him on a nonrebreather, on a stair chair, out to the ambulance, and lights and sirens half way to the hospital before we realized we didn’t who he was, and he was still working at breathing too hard to get a syllable out. No name, no DOB, no social, just the address we picked him up at. Chalk that one up to two excited rookies.
On most calls, if you leave the house without the patient’s name, this is no problem, the patient can tell you. In the past, I didn’t often bother with this information if the patient was talking to me. I figured I could get it out in the ambulance. I look at the elderly patient and say “You know your date of birth and social security number?” The patient looks me right in the eye and says “yes, sir.” Very good.
On the way to the hospital, after I have done an IV and 12-lead, I ask the patient for his date of birth. “Yes, sir!” he says. Same answer to social security number. I ask him his name. “Yes, sir!”
Always get the name and social.
I am in the nursing home and the nurse hands me the envelope. I take a quick look at it to see if there is a name, date of birth and social security number filled in on the paperwork and that I can read it. Check. Check. The patient is unresponsive. Out in the ambulance, I am checking the patient’s meds to see if they provide a clue to their condition. I notice then that patient’s name is Mary Wilson. The problem is the patient is a man. I send the paperwork back into the SNF with my partner who comes out with an apology and the paperwork for Richard Johnson.
Here’s one. Nursing home patient is unresponsive. Ambulance crew takes patient and paperwork. Patient’s blood sugar turns out to be 29, but he is not a diabetic. They give him D50, and he comes around, but is still somewhat confused. At the hospital they keep him overnight to do tests and figure out why he dumped his sugar considering he is not a diabetic. Plus he is still confused. He won’t answer to his name. Later that night, the hospital gets a call from the nursing home to check on the patient. Who? The hospital says, we have no one by that name here. Later the hospital calls the nursing home back. We do have someone here from your facility named Edward Thomas. Ahh, no you don’t. Edward is right here next to me in his wheelchair. Whoops. No wonder the man in the hospital bed won’t answer to his name. Turns out the patient is a diabetic after all.
You have to check the name. If the patient can’t confirm it, check for a name bracelet. No bracelet? Get a nurse to verify the patient and paperwork are one and the same.
You’d think it would be easy, but it’s not. The times I’ve been on calls and had a first responder hand me a piece of paper with the patient’s name and information on it, and its been the first responder’s previous patient, and not this current one. The times it has been the right patient and I have put the paper in my right pocket, but then pulled a piece of paper out of my left pocket and started typing in the name on the left pocket piece of paper. Not the patient in front of me.
I try hard now. I introduce myself to the patient and get the patient’s name or get someone to tell me the patient’s name. Mistaken identity can lead to serious errors, and those we always want to avoid.