Page 66 - CPE E-BOOK ROUGH COPY

University Health Network
Policy & Procedure Manual
S Sp pi ir ri it tu ua al l C Ca ar re e

S Sp pi ir ri it tu ua al l C Ca ar re e S Se er rv vi ic ce e – – P Po os si it ti iv ve e P Pa at ti ie en nt t I Id de en nt ti if fi ie er rs s

Policy

The Department of Spiritual Care is committed to providing high quality and safe patient care by
ensuring positive patient identification where a two-identifier system is always used for patient
identification. It is expected that all Spiritual Care staff use positive patient identification in both
inpatient and outpatient settings. Please refer to policy number 3.30.016 for more information.

Procedure

1. Positive patient identification will occur prior to any assessment or service with all
patients and families.
2. Positive patient identification is a requirement at the beginning of each patient visit
3. Two of four unique identifiers as laid out by UHN must be used. These identifiers are:
 Patients full name
 Date of birth
 MRN number
 Home address
4. Check patients identification bands, patient identification cards or obtain verbal
confirmation of their full name and date of birth or MRN number before providing any
service
 Never use patient’s room number for patient identification purposes
5. For Unconscious, Unidentified, or Impaired Patients:
 Identify the patient using personal identification found on the patient.
 If unable to identify the patient using personal ID, have a family member verify
the patient’s identity.

This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by any
person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without permission of
UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number 20-004 Original Date 10/15/14
Section Spiritual Care Services Revision Date(s)
Issued By Department of Spiritual Care Review Date 10/15/17
Approved By Clinical Director Page 1 of 1