Administrative Data Documentation
Administrative data are coded information contained in secondary records (such as billing records) describing patient identification and insurance. Patient registration information would be considered administrative data as would patient account information.
Patient Registration Information Documentation
Patient registration information includes those data elements obtained during the patient registration process. Most of the patient registration process usually takes place before the physician examines or begins treating the patient. During the registration, process, demographic data are collected. Demographic data are data that identify the patient and includes the following:
- Patient’s full name (including any aliases the patient uses; for example, Bob instead of Robert)
- Patient’s health record number if the patient was not seen at the healthcare organization before. as well as a patient’s account number for this specific visit
- Patient’s address
- Patient’s contact phone number
- Patient’s date of birth
- Patient’s gender
- Patient’s marital status
- Patient’s religious affiliation (if patient has one and chooses to disclose it)
- Race (often this is optional)
- Next of kin information
- Healthcare power of attorney or advance directives (if the patient has these documents) (refer to chapter 8 for specifics)
- If the patient wants to be a private or confidential patient under HIPAA, where the patient opts-out of the healthcare organization’s directory (discussed in chapter 9, Data Privacy and Confidentiality)
