Add/Edit Patient Records

Before a patient record can be added or edited, a search must be conducted first. Authorized users can indicate on the simple search page that a new patient record will be added, however.

Add a New Patient Record (Simple Method)

On the simple Patient Search page, select the Check here if adding a new patient option. Enter the patient information in the required fields (marked with red text after the option is selected). The required fields are:

Click Search, verify the patient is not listed in the search results, and (if not listed) click Add Patient. The Patient Demographics Edit page opens with the search criteria fields automatically populated.

If you would like to use your default patient settings, select Apply Defaults from Personal Settings to this Record. See User Preferences Default Settings.

Enter as much information as possible and click Save to save the information and return to the previous page. If configured, you can click Save & Continue (or similarly named button) to save the information and queue the patient into the Waiting Room. See Waiting Room for more information.

The available fields and their descriptions are as follows. Note that depending on your state's configuration settings, not all of the fields display on the page.

NOTE: The patient demographics display settings, and whether or not multiple rows are allowed, are configured in the Administration > Settings > Patient Demographics Display Settings options.

Field

Description

Patient Status

Active is the default. To inactivate the patient, select a reason from the drop-down list. Examples include:

Deceased
Inactive - Lost to follow-up
Inactive - No longer a patient

If selecting a status other than Active, a confirmation message appears. Click Yes or OK to continue.

First Name

Enter the patient's first name. This is a required field. These can also be used as a first name at the birthing hospital when a baby does not have a name:

BABY
BABY BOY
BABY GIRL
NEWBORN
GIRL
FC1
FC2
FC3
MC1
MC2
MC3

Middle Name

Enter the patient's middle name.

Last Name

Enter the patient's last name. This field is required.

Suffix

Select the patient's suffix from the drop-down list. Example: Jr., Sr., IV.

Birth Date

Enter the patient's birth date.

NOTE: If an attempt is made to change a patient's birthdate to a date earlier than the first immunization, an error displays. A determination must be made as to whether the birthdate or the immunization date is incorrect. The same error appears in the case of an import-based birthdate change.

Birth File #

Enter the patient's birth file number.

Sex

Select the patient's gender from the drop-down list. Depending on state configuration settings, if the patient's sex is changed, a confirmation message may appear.

Mother's Maiden Name

This may or may not be a required field, depending on state settings. Enter the patient's mother's birth-given last name. This is not required if the patient is 19 years old or older. For family validation, the Guardian First Name, Mother Maiden Name, and Guardian SSN may be required.

Military

Select this option if the patient was in the military.

Comments

Enter any additional information about the patient.

Race

Select one or more races from the list.

Ethnicity

Select the patient's ethnicity from the drop-down list. This field may or may not be required.

Language

Select the patient's language from the drop-down list.

SSN

Enter the patient's Social Security Number, either the full number or the last four digits, depending on display settings. This field is only fully available when adding a new patient and is stored in the database for deduplication purposes. However, if the Administration > Settings > Properties > Patient Settings > Prevent Display of Patient and Guardian Social Security Numbers option is enabled, only the last four digits are displayed on the Patient Demographics page.

Medicaid #

Enter the patient's Medicaid number.

Birth Order / Multiple Birth Indicator

This field is used when adding twins, triplets, etc. Enter a single whole number indicating the patient's birth order. For example, when entering twins, the birth order would be 1 or 2. When combined with the multiple birth count field, the end result is 1 of 2 and 2 of 2. A confirmation dialog box appears to confirm that you are entering multiple births; click OK.

NOTE: The Birth Order and Multiple Birth Indicator fields are merged on the Patient Demographics page. The field is Multiple Birth and the data is the birth order (first number) and multiple birth count number (second number). After the birth order has been saved, only a Registry Client user can edit the field.

VFC Status (Wyoming: WYVIP Status)

Select the VFC/WYVIP status if the patient is under age 19. This field may or may not be required. New patients added at age 19 or older are automatically marked as ineligible.

Block Recall

To limit the types of reminder/recalls the patient receives, select the HL7 publicity description from the drop-down list. Examples:

No reminder/recall
Reminder/recall - any method
Reminder/recall - no calls
Reminder only - any method
Reminder only - no calls
Recall only - any method

Recall only - no calls
Reminder/recall - to provider
Reminder to provider
Only reminder to provider, no recall
Recall to provider
Only recall to provider, no reminder

Vaccine Supply

On Patient Demographic Master View page only (cannot be edited). Denotes the type of vaccine supplied by the health plan and VFC status eligibility for patients under age 19. Displays either Public or Private and is based on the VFC status.

If the VFC status is ineligible, the vaccine supply displays Private and a selection from the health plan drop-down list may be required.
If the VFC status is anything other than ineligible, the vaccine supply displays Public.

Comments

Enter any comments.

To display this section on the Patient Demographics page, select the Display option for Administration > Settings > Patient Demographics Display Settings > Address. To allow multiple rows (multiple entries for fields) in this section, select the Multi-Row option.

Field	Description
Address / Address 1 & 2	Enter a PO Box or the first line of a street address. If this field is labeled Address 1, enter the PO Box in this field and the street address in the Address 2 field. The following abbreviations can be used: Box (BX) Highway (HWY) Center (CTR) Expressway (EXPY) Heights (HTS) Junction (JCT) Lake (LK) Square (SQ) Station (STA) Northwest (NW), northeast (NE), southwest (SW), southeast (SE) Lot (used in context of apartment or space number) Martin Luther King (Martin L King, MLK) When two addresses are added, make sure the valid checkbox is selected. If it is not, the secondary address does not appear on the patient detail page.
City	If not already populated, enter the city in which the patient lives. This field may or may not be required.
State	Select the patient's state. State must be entered before selecting the county or parish. This field may or may not be required.
Zip Code	Enter the patient's zip code. This field may or may not be required. If the country is other than the U.S. and zip codes have alphabetical and numeric characters, edit your personal settings to deselect the Automatic City / State / Zip Code / County Population option. Disabling this option allows both letters and numbers to be entered into the zip code field. Note that if more than one zip code exists for a city, the Select Zip Code dialog box appears. Otherwise, the zip code is automatically populated.
Country	Select the patient's country. If the country is other than the U.S. and zip codes have alphabetical and numeric characters, edit your personal settings to deselect the Automatic City / State / Zip Code / County Population option. Disabling this option allows both letters and numbers to be entered into the zip code field.
County/Parish	Enter the patient's county or parish. The state must be entered first.
Address Type	This field appears only if set up in Define Lookups. Select the type of address entered. Examples include Shipping, Billing, Mailing, Physical, Legal.
Email	Enter the patient's email address, which is used for reminder/recall notices.
Valid	This field appears if configured. Select this option if the address is valid. If not selected, the address is not valid and mailings are not attempted. When two addresses are added, make sure the valid checkbox is selected. If it is not, the secondary address does not appear on the patient detail page.
Primary	If multiple addresses are entered, select the radio button for the address that is the patient's primary address. Only one address can be primary. The primary address is stored in the Patient Master and Reserve tables; the remaining addresses are stored in the Many to One table.
Add	Click the Add button after entering the address information. The information is not saved until the Add button is clicked. After the button is clicked, the address information can be edited or removed by clicking the Edit or Remove button. Multiple addresses can be added.

Field	Description
Phone Number	Enter the patient's phone number. If set in the User Preferences, the area code is automatically populated. This field may or may not be required. If this is the primary phone number, select the radio button in the Primary column. To add additional phone numbers, click Add.
Extension	If applicable, enter the extension number for the patient's phone number.
Phone Use Code	Select a phone use code from the drop-down list. Examples include Primary residence number, work number, emergency number.
Equipment Type	Select the equipment type from the drop-down list. Examples include Telephone, Cellular Phone, Telecommunication Device for the Deaf.
Primary	Select the radio button in the Primary column for the patient's primary phone number.
Add	Click the Add button after entering the phone number information. The information is not saved until the Add button is clicked. After the button is clicked, the phone number information can be edited or removed by clicking the Edit or Remove button. Multiple phone numbers can be added.

To add multiple phone numbers, enter the information and then click the Add button. The information is not saved until Add is clicked.

To display this section on the Patient Demographics page, select the Display option for Administration > Settings > Patient Demographics Display Settings > Family and Contact Information. To allow multiple rows (multiple entries for fields) in this section, select the Multi-Row option.

Field	Description
Guardian 1 First	Fields are state-configurable and may be labeled differently. Enter the first name of the patient's first guardian.
Guardian 1 Middle	Enter the patient's guardian's middle name.
Guardian 1 Last	Enter the patient's guardian's last name.
Contact Type	If available, select the patient's family contact type from the drop-down list. Contact types are created by the System Administrator in Define Lookups.
Guardian Work Phone	Enter the work phone number for the patient's guardian.
Guardian 1 SSN	Enter the patient's guardian's Social Security Number. This field is only fully available when adding a new patient. If the Administration > Settings > Properties > Patient Settings > Prevent Display of Patient and Guardian Social Security Numbers option is enabled, only the last four digits are displayed on the Patient Demographics page.
Guardian 2 First	Enter the first name of the patient's second guardian.
Guardian 2 Last	Enter the last name of the patient's second guardian.

Field	Description
First Name	Enter the parent or guardian's first name.
Middle Name	Enter the parent or guardian's middle name.
Last Name	Enter the parent or guardian's last name.
Contact Type	Select the contact type from the drop-down list.
SSN	Enter the patient's guardian's Social Security Number. This field is only fully available when adding a new patient. If the Administration > Settings > Properties > Patient Settings > Prevent Display of Patient and Guardian Social Security Numbers option is enabled, only the last four digits are displayed on the Patient Demographics page.
Guardian?	Select this option if this person is the patient's legal guardian.
Address 1	Enter the first line of the parent or guardian's address.
Address 2	Enter the second line of the address.
City	Enter the parent or guardian's city.
Country	Select the parent or guardian's country from the drop-down list.
State	Select the parent or guardian's state from the drop-down list.
Zip Code	Enter the parent or guardian's zip code.
Phone	Enter the parent or guardian's phone number.
Email	Enter the parent or guardian's email address.
Add	Click the Add button after entering the information for each parent, guardian, or other family member. The information is not saved until the Add button is clicked. After the button is clicked, the family member or contact person is listed and can be edited or removed by clicking the Edit or Remove button.

To display this section on the Patient Demographics page, select the Display option for Administration > Settings > Patient Demographics Display Settings > Alias. To allow multiple rows (multiple entries for fields) in this section, select the Multi-Row option.

Field	Description
First Name	If the patient uses (or has used) another first name, enter it here. Alias fields are included in searches.
Last Name	If the patient uses (or has used) another last name, enter it here. Alias fields are included in searches.

To display this section on the Patient Demographics page, select the Display option for Administration > Settings > Patient Demographics Display Settings > Secondary Patient Information.

Field	Description
Allergies	Enter any noted allergies for the patient.
Monthly Income	Enter the monthly gross income of the patient's family.
Association	Select an association to which the patient may belong, such as Fire Station, Police, etc., from the drop-down list. This is state-configurable and may not contain any entries.
Number in Family	Enter the total number of family members.

Field

Description

School

Enter the patient's school name. The School Nurse module may automatically pre-populate this field. Otherwise, click Click to select to open a pop-up window and search for the school.

NOTE: If the school is changed in IWeb, the change is not automatically sent to the School Nurse module. However, if the school nurse changes the school name in the School Nurse module, the change is automatically sent to IWeb.

School Entry Date

Enter the date the patient started the school named in the School field. This is a required field for School Nurse users.

To display this section on the Patient Demographics page, select the Display option for Administration > Settings > Patient Demographics Display Settings > Insurance. To allow multiple rows (multiple entries for fields) in this section, select the Multi-Row option.

Field	Description
Health Plan	Select the patient's health plan from the drop-down list. This is a required field for patients whose VFC status is ineligible and who are 18 years old and younger.
Other Health Plan	If Other is selected in the Health Plan drop-down, enter the plan name in the textbox.
NAIC Code	Enter the NAIC code number.
Enroll Date	Enter the effective date for health plan enrollment.
Medicare ID	Enter the patient's Medicare ID number (US only).
Billing ID	Enter the patient's billing number.

To display this section on the Patient Demographics page, select the Display option for Administration > Settings > Patient Demographics Display Settings > Medical Home.

Field	Description
Physician	Select the patient's primary care physician from the drop-down list. If set in User Preferences, it automatically populates.
Facility	Select the medical home facility from the drop-down list. If set in User Preferences, it automatically populates. The abbreviated name of the Facility may be used in the list instead of the full name.
Admission Date	Enter the date the patient was admitted to the medical home facility, or the date of entry if this is a new patient. If the user does not belong to an owning Organization (IRMS), this field is disabled. It cannot be edited.
District/Region	Enter the medical home facility's district or region. If set in User Preferences, it automatically populates.
Next Appt. Date	Enter the date of the patient's next appointment. This date is used in reminder/recall.
Chart Number	Enter the patient's chart number.
Medicaid Provider #	Enter the patient's Medicaid provider number (US only). It can be populated either by Medicaid bath imports or by provider data entry.

Field	Description
Birth Facility	Enter the patient's birth facility.
Birth Country	Select the patient's country of birth from the drop-down list.
Birth State	Select the patient's birth state from the drop-down list.
Date of Death	If applicable, enter the patient's date of death. This field is available only if the patient has been inactivated with the reason of Deceased. This cannot be a date in the future.

If patient-specific reports are available to states, they are listed in this section of the page. The list below contains some example reports, which may not be available to all states.

Field	Description
Certificate of Immunization Status (Washington)	Click the Certificate of Immunization Status (CIS) link to open the Certificate of Immunization Status (CIS) page. Select the Certificate Type from the drop-down list (i.e., Child Care, School Nurse) and then the Series from that drop-down list, then click Create PDF. The PDF version of that certificate for the selected patient automatically downloads.
Adult Immunization Record (Tennessee)	See Adult Immunization Record.

Receipt of the HIPAA Private Practices Form by Parent/Guardian/Third Party Section:

Field	Description
HIPAA Private Practices Form Given	Select this option if the patient was given the HIPAA Private Practices form.
Date Given	Enter the date the HIPAA Private Practices form was given to the patient.
Signature	If a signature pad is connected and the related software installed, have the authorized person sign the form and then click: Edit - To make edits to the form data (date given, re-signature) Clear - To erase the input fields Done - To save and store the signature

These fields may or may not display, depending on application version number or module availability.

Field	Description
HP Patient ID	Enter the patient's health plan ID number.
Block Health Promotion Reason	Select a reason to explain why health promotion mailing should not be sent to the patient. This field is called Block Mail Reason in manual deduplication.
Recall Count Attempts	Displays the number of times the patient has been sent a reminder recall. Automatically generated by the system.
High Risk	High risk categories are added at the state level. These categories make it easier to identify patients with possible special immunization needs. If this field is highlighted in red, (s)he may have special immunization needs.

Field	Description
Campaign Name/Tier Name	If the Required Campaign option is enabled (selected) on the Campaign Add/Edit page, this fields may appear on the Vaccination Detail, Contraindications, and Patient Demographics Detail/Edit pages to identify the campaign or tier name.

Field	Description
SIIS Patient ID	The patient's SIIS number.
IRMS Owner	The Organization (IRMS) that "owns" the record. This field can be configured so that it appears blank on patient demographics and vaccination detail pages.
Entry Date	The date the patient was entered into the application.
Last Update Date	The date the patient's information was last updated.
Entered By	The username of the person who created/entered the patient record.
Last Updated By	The username of the person who last updated the patient record.

Field	Description
Include in CASA	Select this option to include the patient in CASA for the current session. This only appears when enabled in Administration > Settings > Properties > Registry Settings > Allow CASA Export by Session. See CASA Export for more information.
Do Not take Ownership of This Record	Select this option to prevent the Organization (IRMS) from taking ownership of the patient record. When enabled (selected), a message appears at the top of the Vaccination Detail page when shots are administered, notifying the user that upon saving the vaccination(s), ownership will not be taken by the IRMS. Ownership remains with the previous owning IRMS and is not changed to the IRMS making the edit or adding the shot(s). However, If the user account does not allow changes to records, or if the IRMS is blocked from ownership, then this option does not appear. If the IRMS that the user is logged in as already owns this patient, this option does not appear.
Opt Out	When this option is selected, a warning message appears: Are you sure you want to opt out for this patient? Click OK to confirm or Cancel to abort opting out. After this option is selected, all personal data is removed from the Patient Master and Patient Reserve tables. The remaining data includes the IRMS ID, patient birth date, VFC status, and inactive status. The record is also flagged as anonymous. Note: In order for this option to display, the organization selected by the Registry Client user at login must be the same organization that last updated the patient record.
Share with Other Registries	This is a state-configurable option. If enabled (selected), the patient record can be exported via HL7 to remote registries (both the state central registry and state-to-state). Records that are not selected are not exported. This option does not affect incoming updates to patient records (vaccsync, queries, etc.). The option cannot be transferred or changed during updates from external systems.

In the sections of the page that allow multiple entries (if configured) - for example, additional phone numbers - click the Add button in that section, then enter the information in the fields.

Add a New Patient Record (Advanced Method)

On the advanced Patient Search page, select the Add/Edit/View option (located under the buttons) if it is not already selected. Enter the search criteria (at a minimum, enter the First Name, Last Name, and Birth Date). If the patient is underage 19, also enter the Guardian's First Name, SSN, and Mother's Maiden Name (last name only). Also enter the address. Click Search.

Check for an existing record in the search results. If none exists, click Add Patient. The Patient Demographics Edit page opens with the search criteria fields automatically populated.

If you would like to use your default patient settings, select Apply Defaults from Personal Settings to this Record. See User Preferences Default Settings.

Enter as much information as possible about the patient and click Save. See the previous section for information about the available fields on this page and their descriptions.

Opt Patient Out of the Registry

Patients can opt out of being part of the registry, at which time their data is made anonymous (see Anonymous Patients for more information). To opt the patient out of the registry, click the Opt Patient Out button on the Patient Demographics page. A confirmation message appears on the page. To opt the patient back in, click Opt Patient In.

Anonymous Patients

Anonymous patients are those who have opted out, or are exempt from, the registry. Adding a patient anonymously allows the patient's vaccination data to be included in the central registry for inventory and CASA purposes.

Search/Add

To add an anonymous patient, perform a search (using Anonymous%) to ensure that the patient doesn't already exist. Look for the patient in the search results and, if (s)he is listed, click on the row to open the patient demographics for editing. See Edit a Patient Record for more information about editing patient information.

If the patient is not listed in the search results, click the Add Anonymous button. The Patient Add page opens. Enter at least the Birth Date (the other fields are optional) and click Add Patient. (Note that patients who are 19 years old or other automatically receive a VFC Status of ineligible.)

Edit

To edit an anonymous patient, follow the instructions in the Edit a Patient Record section.

An Opt In/Opt Out Patient option is available to Registry Client users. If a patient already exists in the registry, however, a user can only opt out a patient that they own.

Edit a Patient Record

To edit a patient record, first search for it. In the Search Results list, click on the patient's row. The Patient Demographic Master View page opens. Click one of these buttons (which appear depending on configuration settings) to edit the related information (or perform other tasks).