QDPM - Patient Registration
‘New Patient’ Demographic Information
here. Mandatory fields display yellow, lookup fields are indicated by the
magnifying glass. At the Insurance section, select the appropriate item and
then continue to enter valid information and then F2 or click [Save].
FIELD NAME | DESCRIPTION |
Last Name | Patient’s last name |
First Name | Patient’s first name |
Middle | Patient’s middle initial |
Suffix | Suffix, such as Jr., Sr., etc. |
SSN | Social Security Number |
DOB | Date of Birth-mmddyyyy format |
Gender | Patient’s gender |
Marital Status | Divorced, Married, Single, Widowed |
Address | Patient’s street address |
Address Line 2 | Second address |
City | Patient’s city |
State | Patient’s state |
Zip | Based on the City selection |
Home Phone | Patient’s home number |
Work Phone | Patient’s work number |
Cell Phone | Patient’s mobile number |
Check Refused if none is provided | |
Reminder Preference | Choose if using a call reminder service |
Is Patient Guarantor? | Yes, No |
Primary Insurance | If none is Chosen = Self Pay |
Statement | Defaults to system setting |
Signature | Default value ~ B |
Sign Date | ‘T’ to populate today, or double click for calendar |
Chart Number | Chart number if applicable |
Patient Type | User Defined field |
Patient Code | User Defined field |
Assigned Provider | Provider Library |
Facility | Service Facility Library |
PCP | Primary Care Physician -Referring Physician Library |
Referral Provider | Referring Physician Library |
Race | Use checkboxes |
Ethnicity | Hispanic/Latino or Not or refused |
Language | Patient’s primary language |
English Proficiency | Very well > not at all |
Employment Status | EF, EP, SF, SP, R, U |
Employer | Name of employer |
New Patient Date | Auto populates for new patients |
Last Visit | Auto populates |
HIPPA signed | Yes/No |