This document outlines patient identification policies and procedures at The Central Hospital in Sri Lanka. It defines different types of patients and establishes that all patients must be positively identified using their name and date of birth. It describes the process of registering patients and applying identification bands at admission or first encounter. It also requires reconfirming patient identification before any medical intervention using a three-point verification of the patient's name, date of birth, and unique hospital identification number against their identification band and records. The document provides detailed policies for identifying different patient groups like infants, unidentified patients, and those undergoing procedures. It also describes monitoring and auditing processes to ensure compliance with the patient identification policies.

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THE CENTRAL HOSPITAL,
COLOMBO, SRI LANKA
PREPARED BY: NAME: DR. ARUNI MUNASINGHE,
DESIGNATION: JCI CHAPTER
CHAMPION
SIGNATURE:
STAMP:
DATE:
REVIEWED BY: NAME: DR. RUWAN SENATILLEKE
DESIGNATION: CHAIRPERSON,
ASIRI HOSPITALS POLICY REVIEW
COMMITTEE
SIGNATURE:
STAMP:
DATE:
APPROVED BY: NAME: DR. MANJULA
KARUNARATNE
DESIGNATION: DEPUTY CHIEF
EXECUTIVE OFFICE
SIGNATURE:
STAMP:
DATE:
JCI ACCREDITATION
STANDARDS FOR
HOSPITALS – 5TH
EDITION
SECTION II: PATIENT
– CENTERED
STANDARDS
CHAPTER: INTERNATIONAL
PATIENT SAFETY GOALS (IPSG)
DOCUMENT IDENTIFICATION NO:
CHL/HP/IPSG.01
DOCUMENT TITLE:
PATIENT IDENTIFICATION
STANDARDS REFERENCE:
IPSG.1
REVISION NO: 0
DATE OF REVISION: NA
ISSUE NO: 1
DATE OF ISSUE: 15 DECEMBER
2014
NUMBER OF PAGES: 14

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A. PURPOSE
The purpose of this Policy is to reliably identify the patient as the correct person for
whom the service or treatment is intended and to match the service or treatment to that
individual at all times throughout the hospital in a standardized manner.
B. DEFINITION
Identification
Correct patient identification is achieved when all health care workers in the Hospital
(CHL) are able to confirm the identity information provided by the patient, guardian or
patient’s representative, and consistently match those on the patient’s identity band and
other identifiers provided by CHL in all locations throughout the hospital.
In-patients
In-patients are those patients who are admitted to the hospital and are expected to stay
overnight.
Day patients
Day patients are those patients who are admitted to the hospital for a procedure or
monitoring, but not expected to stay overnight.
Out-patients (Ambulatory Care)
Out-patients are those patients who attend the Out-Patient Department for a
consultation or to undergo a procedure, but who are not admitted as in-patients or day
patients Out-patients do not require the in-depth level of care as that of an in-patient.
Cognitively compromised / impaired patients
Patients who are confused in any way and may be unable to reliably identify themselves
and/or the time, date and their location or those patients identified as lacking capacity or
with learning disabilities. This also includes children who are unable to communicate due
to age or disability.
Unidentified patients
This is a patient for whom no identification is known, or whose identification markers are
thought to be unreliable.

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C. SCOPE
All Hospital (CHL) Specialists, Medical Officers, Nurses, Allied Health staff and Non-clinical
staff who come in contact with inpatients, outpatients, day patients, ambulatory patients,
cognitively compromised / impaired patients or unidentified patients in the course of
their duties.
D. JCI RELATED STANDARDS
IPSG.1 The hospital develops and implements a process to improve accuracy of patient
identifications
E. RESPONSIBILITY
1. Medical Director
2. Director Of Nursing
3. Chief Nursing Officer / Assistant Chief Nursing Officers
4. Heads Of All Departments Clinical and Non-Clinical
5. All Clinical / Non Clinical staff
6. Quality Head / Quality Assurance Department
F. POLICY
1.1 It is the policy of the Hospital (CHL) to emphasize the responsibility of the health
care worker to reliably identify the patient as the correct person for whom the
service or treatment is intended and to match the service or treatment to that
individual at all times throughout the hospital.
1.2 It is the policy of Hospital (CHL) that all patients having any medically related
intervention with an CHL health care worker will be identified by the following Two
(2) identifiers:
A. Name; And
B. Date of Birth

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1.3 All admitted patients, Emergency room patients and outpatients undergoing
procedures will have an identity band displaying the name and date of birth and
Unique Hospital Identification Number (UHID), attached to them at the time of
admission or first encounter in the case of outpatients.
1.4 It is the policy of CHL to use the two identifiers and UHID together in a 3-Point
Verification exercise at each and every medically related encounter to avoid wrong
patient errors.
G. PROCEDURE
The procedures by which the various categories of patients are identified by health care
workers at CHL are outlined below and encompass the following:
1. Identification Procedures
2. Identification Band
3. Addressographs
IDENTIFICATION PROCEDURES
1. Positive Patient Identification for Admission & Registration
1.1 Patient identification for Registration at Admission
A. Conscious and / or Mentally Alert patients – self-identification is acceptable
using the National Identity Card (NIC) number. Information required at
Registration is as follows:
Name with initials:
Date of Birth: Date / Month / Year
Address:
NIC / Passport number
UHID
B. Unconscious and/or confused patient may be identified:
- By Guardian / family member / accompanying person providing patients
NIC number
- By demographic data sent with patient from referring facility
- By Police and/or investigating officers
C. Non-English speaking patients

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Reasonable and effective efforts must be made to find a translator who
speaks the patients / guardian / family member or accompanying person’s
language to secure the NIC number and/or other identification i.e. Passport
number, Driving / License Number or Postal ID Number in Sri Lanka.
D. Unidentifiable patients
Where the preceding methods of identification have proven unsatisfactory
e.g. where there are unconscious patients or are unaccompanied patients
with questionable identity , the patient may be identified as follows:
i. Unknown Male / will be known as Ranbanda for a male and
Ranmenike for females
ii. A Unique Hospital Identification Number (UHID) is assigned to the
patient in question (11111, 11112 an so forth)
iii. The age of the patient will be estimated by a Physician
iv. A patient’s wristband will be attached to the patients arm containing
Ranbanda / Ranmenike and UHID assigned to the patient e.g.
Ranbanda / 11111 or Ranmenike / 11123.
E. Unidentifiable patients will remain in this state (Ranbanda / 11111 or
Ranmenike / 11123) until Positive Patient Identification is made by a
guardian / family member / accompanying person or Police investigation.
1.2 Where no NIC number is available, a strict period of 48 hours is given to the
patient, guardian or patient’s representative to secure the NIC number. The
patient registration staff will follow-up and secure the NIC number within 48
hours.
1.3 If not successful after 48 hours, the patient registration staff may utilize any of
the following:
- Passport number
- Driving / License Number
- Postal ID Number
- UHID
1.4 The two mandatory positive identifiers would be the Name and Date of Birth. In
addition the UHID may be used.

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1.5 Procedure after Positive Identification Recorded by Hospital
The information must be recorded in the Admission/Patient Registration Form in
the Hospital Information System (HIS) at the Admission Counters, Emergency
room, Day units and at registration for Endoscopy, Radiology, TMT,
Physiotherapy and all other units including counters for Labouratory tests.
The Patient is then registered with a Registration Number and a Patient Medical
Record is created with a system generated UHID number and an Identification
Band / Wristband is then attached to the patients arm. An example would be as
follows:
Name/DOB/UHID
2. Identification Band / Wristbands
2.1 An Identification Band or Wristband will be placed at the point of initial patient
contact following Positive Identification of the patient and registration or
admission with a UHID to:
a. All in-patients
b. Emergency department patients
c. Out-patients undergoing operative or invasive procedures
o All patients having biopsies
o All patients undergoing Endoscopies
o All patients undergoing CT/MRI/PET scans (may need sedation,
contrast)
o All patients undergoing Hemodialysis
NOTE - All patients receiving a blood transfusion are already admitted according
to hospital policy and therefore have ID bands.
3. Out-Patient identification
Out-Patient’s not undergoing an operative or invasive procedure (such as routine
Labouratory and USG Scan or X-Ray patients who do not receive an identification
band) will be identified through confirmation of their Name and Date of Birth by the
relevant hospital personnel e.g. Radiographer, Radiologist, pharmacist , ECG
technician and in the case of TMT by the technician as well as the medical officer (the
Hospital bill for such Out-Patient services shall contain the Name and Date of Birth of
the patient).

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4. Patient Medical Records
4.1 All health information and medical records relating to a patient who is admitted
must bear the patient Registration Number and UHID.
4.2 Patient labels generated by the registration and admission process will be affixed
to each document created for a patient including Addressographs.
5. Patient Identification Reconfirmation Process before Procedures
5.1 The two mandatory identifiers the Name and Date of Birth, and, the UHID
Number will be used to reconfirm patient identification prior to every instance
of:
5.1.1 Administering medications or blood products,
5.1.2 Taking blood samples, and other specimens for clinical testing,
5.1.3 Performing other treatments or procedures (all surgery, Radiographic
procedures, arrhymia, studies, Hemodialysis)
5.1.4 Prior to insertion of an intravenous line
5.1.5 Prior to serving a restricted diet tray
The patient’s Name and Date of Birth and UHID Number on the Identification
Band / Wristband will be verified with the patient / guardian / family member by
verbally stating the Name and D.O.B. at each encounter as well as against the
identifiers on the requisition, medication or specimen collection container label,
or medical record to ensure proper identification (3 point verification) All
requisitions, specimen forms and PMR to contain Addressographs. (Refer to
Attachment C)
5.2 Active rather than passive communication to be used in reconfirmation of
identity. (Active communication is when Patient states Name and D.O.B. Passive
communication - is when caregiver states name and D.O.B. and patient
acknowledges)
5.3 Two persons are required (House physician and Nurse in charge) to match the
blood pack using the two patient identifiers (name, D.O.B.) B.H.T., Blood Group
for compatibility
5.4 All blood and specimen collection containers are to be labeled in the presence of
the patient at the time of collection. (Using Addressographs)

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5.5 When drugs or blood products are administered Patient education and
participation is required.
5.6 All surgical patients are to be identified using name, date of birth, surgery with
site and side during scheduling, time of admission, and prior to surgery.
6. Patient Identification Reconfirmation Process before collection of
Specimens
6.1 All registered and admitted patients at CHL having laboratory or blood banks
samples taken must be identified by a properly attached Identification band /
Wristband before specimen collection begins.
6.2 The minimum information required on a specimen label shall be as follows:
a. In-Patients - Patient’s full name / Registration Number & UHID number /
Date and Time of collection of sample / ward & location / Collectors
identification
b. Out-Patient’s - Patient’s full name / Registration Number & UHID number
/ location /Date and Time of collection of sample / Collectors identification
6.3 All specimens must be labelled immediately after collection in the presence of
the patient .
6.4 Errors or omissions in labelling will result in a request for a new sample. Rejected
specimens must be documented in the second request form.
6.5 Specimens of donors drawn should be labeled as follows:
a. the full name and NIC of the Donor (if external)
b. Registration Number/UHID number if the Donor is a registered patient at
CHL
c. the full name and NIC of the Donee (if external)
d. Registration Number/UHID number if the Donee is a registered patient at
CHL
e. the and Date & Time and
f. Collectors identification
7. Irreplaceable Specimens

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7.1 Special care must be taken to properly label irreplaceable specimens
7.2 In the event that an irreplaceable specimen arrives in the Laboratory unlabeled
or incorrectly labelled, all reasonable attempts must be made to determine
positive identification
7.3 Specimens will be processed after positive identification has been made
7.4 If the patients does not have an Identification band / Wristband, routine blood
/specimen collection will not be done until definitive identification can be
stablished as per procedure.
8. Patient identification in the Emergency Department
8.1 This shall be similar as outlined for In-Patients above.
9. Identification of Infants / Neonates
9.1 Hospital identification Bands / Wristbands are prepared by the Labour / Delivery
staff with the Mothers Registration Number & UHID Number / Full name /
Infants sex / Birth date and Birth time.
9.2 If the mother is awake the Labour / Delivery Nurse must show her the
Identification Band / Wristbands to verify that the name and sex of the infant is
correct on the Identification Bands.
9.3 Once confirmed the Labour / Delivery Nurse will enter the information into the
baby’s chart at the Mothers bedside.
9.4 The Labour / Delivery Nurse will then place one band on the Mothers arm and
one Band on the Infants arm. A second band will be placed on the Infants leg
after the Infants initial bath.
9.5 If the Mother is unable to check and verify the Identification bands / Wristbands
before the infant is taken to the NNICU, one Senior Nurse and one assisting
Nurse shall verify and check all information. This procedure must be completed
before the Infant is taken away from the delivery area. All identification
information is to be included in all appropriate forms.

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10. Procedure if two or more patients in a ward have the same family name
“PATIENT WITH THE SAME NAME IN WARD” cautionary card must be applied to each
patient’s Patient Medical Record. Alerts must be applied to all ward bed lists and
other documentation while both patients remain in the ward and similar cautions
applied during patient handovers. The patient’s given names should be printed on
the cards.
11. Monitoring compliance and Audits
The Medical Director / Chief Nursing Officer / Assistant Chief Nursing Officers on daily
rounds will perform random checks to ensure the adherence to this policy. All cases
of non-identification (patients with missing ID Bands) / misidentification, must be
written on the Incident Report forms and investigated with a report given to the
Medical Director.
All data of misidentification is to be reviewed for progress every 3 weeks / monthly
by the QA Department or a committee appointed by the Medical Director
IDENTIFICATION BAND
Pre-admission all patients are to be informed through the admission brochure the
importance of wearing the ID band throughout the hospital stay until discharge. ID
bands are to be issued in duplicate at Admission. One ID band is to be worn by the
patient, and the second to be in the PMR to be used in case of replacement.
1. ID bands should be worn during transfer of patients to other hospitals. In the
case of patient transferred to the hospital, ID to be verified at initial contact, ID
band to be placed at admission to the hospital.
2. The preferred placement of the patient ID band is the wrist of the dominant
hand unless physical condition or procedure precludes this (in which case
another extremity is used).
3. ID bands should contain Patients Name, Date of Birth (D.O.B.), and PMR. In the
case of neonate’s mother’s full name, Gender, Date and time of birth will also be
included.
4. Patient Name, Date of Birth and UHID are to be used as mandatory patient
identifiers.
5. ID bands are not to be altered, if alteration is necessary, a fresh ID band shall be
applied for.

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6. All patients to wear single ID bands other than neonates who will wear two ID
bands.
7. All ID bands to have white background with black print.
8. ID bands to contain in addition to patient identifiers Red stickers for patients
with allergies, and Blue stickers to for patients with High Falls Risk and Yellow
stickers for infectious patients.
9. Where the details of the ID band do not match patient details all procedures and
treatment should be halted until fresh identification is established and a correct
ID band attached.
10. If a patient is unable to wear a wristband due to their clinical condition, an
alternative method of identification must be sought (ID tag on patient’s bed).
11. If an ID band must be removed for procedural access or other clinical
circumstance, duplicate ID band on PMR obtained, the information is verified by
comparing the patient identifiers on the new band with that of the band to be
removed, and ID band is replaced at an alternate site.
12. If at any time, the patient is found to not have an ID band, the initial
identification process must be performed and an ID band applied after reporting
it as an adverse incident by the personnel who first observed the lack of an ID
band.
ADDRESSOGRAPHS
All patients to be issued Addressographs with the Patient Medical Record (PMR) on
admission.
Addressographs to be issued in two sizes. Standard for PMR and other documents (listed
below) and small, for specimen labelling.
The Large to contain Patient name with initials.
D.O. B. Age,
PMR No. UHID
Physician:
On all Pages of the PMR and all attached documents:
Temperature charts
Fluid Balance Charts

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Diet charts
Nursing notes
Drug charts
Flow charts
Requests for investigations
Falls assessment, Pain assessment
Neuro observation/Weight charts
Small Addressographs on all specimens.
Patient name with initials;
D.O.B. SEX. P.M.R.
In the event that initial Addressographs are inadequate or contain errors Admissions
counter to be notified for further supplies and corrections.
H. IMPLEMENTATION
1. Accurate and timely identification of all patients is the responsibility of the
following:
b) Medical Director
c) Nursing Director
d) Chief Nursing Officer / Assistant Chief Nursing Officers
e) All Consultants
f) All Physicians / Medical Officers
g) All Nursing Supervisors / Nurses / Staff in all departments
h) Admission Counter staff
i) Outpatient Department staff
j) Blood Bank / Radiology / Labouratory staff
k) Medical Records Dept. staff
2. Training needs and modules have been developed and all those that require training
have been identified in collabouration with the Human Resource department who
will coordinate and track all training requirements
I. REFERENCES

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JCI ACCREDITATION STANDARDS FOR HOSPITALS – 5TH
EDITION (EFFECTIVE 1ST
APRIL
2014)
J. POLICIES CROSS-LINKAGES
1. AOP 5.7 ME2 – linked to Section 6 of this Policy – collection of Sample specimens
J. ATTACHMENTS
ATTACHMENT A – SAMPLE PATIENT REGISTRATION FORM
ATTACHMENT B – ID BAND IMAGE
ATTACHMENT C – SAMPLE ADDRESOGRAPHS