Patient intake

The Clinical Coordinator creates the patient record before the first visit. A patient number distinguishes people with similar names, while contact details let the team reach the right person about an appointment or follow-up. The assigned clinician links intake to the person who will handle clinical work. During a pilot, choose one numbering convention and check that staff search by both number and name.

A patient’s consent status gives the team a quick intake signal. Purpose-specific consent belongs in its own signed record, with a version and document when one is used. A status change on the patient does not replace the signed document. If a patient withdraws consent, the team should check the affected work before continuing the visit.

• Identity. Keep the patient number, name, birth date and contact phone with the person, not in a visit note.
• Assignment. Point the patient to the clinician responsible for the next clinical handoff.
• Consent. Review both the patient’s intake status and the purpose-specific consent record.

A returning patient keeps one identity while each new visit gets a separate encounter. This matters when food entries or restrictions are reviewed over time: the care team can see the current patient record without treating every appointment as a new person.

Decide who can create a patient, who confirms a duplicate, and when the assigned clinician changes. Agree on the consent purposes and document versions used in daily work. The Clinical Governance Administrator should confirm which care-team assignments need an effective period and access purpose. These choices affect access to clinical work as well as intake quality.

Before broad use, enter a representative returning patient and a new patient with similar names. Ask the coordinator to locate each by patient number and confirm the correct clinician. Then check that the clinician can see the records needed for their assigned work without changing governance records.

A patient arrives for a nutrition consultation. The coordinator finds the patient by number, confirms the contact phone, and checks that the assigned clinician is current. The consent record is still pending, so the team obtains the signature for the intended purpose before treating it as signed. The coordinator then opens an encounter for this visit. A prior food entry stays connected to the patient and can be read in context; it is not copied into the new encounter.

If the patient’s consent was withdrawn after an earlier visit, the history still explains the earlier signed record. The team pauses the new use of that consent and follows its local policy. This keeps an old signature from becoming an implied permission for a new purpose.

• Patient intake list — Locate patients by number, name, assigned clinician and intake consent status.
• Pending consent — Find purpose-specific records that still need a signature.

Continue with intake and consent and the data model.