Patient Demographics

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Patient Demographics Assignment

As a data steward, you have been asked to create a Microsoft Access database to store patient demographics. Once you have created the database, you must write policies to govern how the data should be collected, stored, and shared. Use search tools to help you write your policies.

Patient Demographics Assignment Part-1: Create Your Access Database

Be sure to include the following demographic elements in your database:

  • Patient First Name
  • Patient Last Name
  • Patient Middle Initial
  • Street Address
  • State
  • Zip Code
  • Phone number
  • Social Security Number
  • Birthdate
  • Gender
  • Emergency Contact Name
  • Emergency Contact Number
  • Primary Physician

Once you have created the database with the patient demographic elements, provide fictitious information for 3 patients for each element.

Part-2: Create Your Policy and Procedure Document

In a Microsoft Word document, create a Policy and Procedure document to govern the collection, storage, and sharing of data. For your convenience, a blank policy and procedure template is provided below.

  • Download: Policy and Procedure Template attached
  • Be sure proper APA formatting is followed and that your assignment is free of spelling and grammar errors.

Patient Demographics Assignment

Patient Demographics


First Name:__________________________________________M.I.______________Last Name:__________________________________________Address:____________________________________________City:___________________________State: __________Zip Code:_______________Phones: (H)_________________________________________(W) ____________________________(C)____________________________________DOB:______________________Age:_________________Sex: M F SSN:_____________________________Marital Status:___________________Ethnicity:___________________________________________Race:____________________________Language: ____________________________Emergency Contact/Phone:__________________________________________________________________________________________________RESPONSIBLE PARTYFirst Name:__________________________________________M.I. _____________Last Name:___________________________________________Address:____________________________________________City:__________________________State: __________Zip Code:________________Phones: (H) _________________________________________(W)___________________________(C)_____________________________________DOB:_______________________Sex: M F SSN:___________________________________Relationship:__________________________________Email Address:____________________________________________________________________________________________________________PHARMACY INFORMATIONPharmacy Name:_________________________________________________Pharmacy Phone #:_________________________________________PRIMARY INSURANCE INFORMATIONInsurance Company:______________________________________________Policy Holder Name:_________________________________________Policy #:_____________________________________________________________Group #:_____________________________________________ Relationship to Patient:_______________________________________________DOB: ______________SSN:_______________________________SECONDARY INSURANCE INFORMATIONInsurance Company:______________________________________________Policy Holder Name:_________________________________________Policy #:______________________________________________________________Group #:____________________________________________Relationship to Patient:________________________________________________DOB:______________SSN:_______________________________REFERRAL SOURCE (Please Circle) Newspaper TV Radio Direct Mail Magazine Website/Internet Billboard Event Friend/Family Other:______________________________________Do you have an advanced directive? (Please Circle) Yes NoMEDICAL INFORMATION: I authorize the physicians of this office to release any information they have acquired in the course of my or my child’s treatment to my insurance company or companies or any third party payor so that they may obtain payment for medical services rendered.INSURANCE AUTHORIZATION: I hereby authorize the physicians or staff of this office to furnish information to my insurance carries concerning myself or my child’s illness and treatments.ASSIGNMENT OF BENEFITS: I authorize the insurance company or any third party payor to pay any benefits due directly to this office should they accept assignment on my claim. I ALSO AGREE THAT I AM FINANCIALLY RESPONSIBLE FOR THE ACCOUNT EVEN THOUGH INSURANCE MAY BE PENDING ON ALL OR A PORTION OF THE CHARGES.Signature:___________________________________________________________________________________Date:__________

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