Create Patient Records

When creating a patient record, all required fields in the Personal, Codes, and Clinical tabs must be completed before a new patient record can be saved. Required fields are configured based on the practice and patient status.

• Personal tab: Contains fields related to the patient’s basic information, including names, demographics, address, status, contact information, assigned personnel, and additional information.
• Codes tab: Contains fields related to the patient’s additional information, alerts, codes, account information, custom fields, and custom information.
• Clinical tab: Contains fields related to the patient’s emergency contact information, physician, picture, and referrals.

Note: This information can be updated after the record is saved.

After the basic patient record has been saved, you can continue on to complete the Guarantor, Employer, and Insurance tabs.

To create a basic patient record:

1. Open the Patients module and search for the patient to ensure they are not already in the system.
2. Click the Add Patient () icon to display the Patient Info – Add Patient window.

Note: The Guarantor, Employer and Insurance tabs only display after you click Save.

3. Complete the Personal tab fields as necessary.
Personal Tab Fields



Field	Description
Title / Last / First / Middle / Preferred	Enter the patient’s title, last, first, middle, and preferred names. Notes: The Preferred field auto-defaults to the First field but may be changed afterward. axiUm searches using the Preferred name entry. The fields can hold a maximum of 30 characters.
Chart	Review the auto-generated patient chart number. Note: This can be changed, if necessary.
[empty field]	A field to the right of the Chart field that displays a unique number for external chart-sorting functions. Note: This is only available if configured in Maintenance.
Fixed	Select the checkbox if only administrators may edit the Chart field.
Sex	Select the patient’s sex from the drop-down list.
Additional Gender Information	Click the + icon to display the Additional Gender Information window. Under Sexual Orientation, complete any of the following: Select the Patient declined to provide the information checkbox if the patient chose not to provide this information. Select a listed entry. Select the Other sexual orientation, please specify: checkbox if their sexual orientation is not listed and enter it in the field below. Under Gender Identity, complete any of the following: Select the Patient declined to provide the information checkbox if the patient chose not to provide this information. Select one or more listed entries. Select the Other gender identity, please specify: checkbox if their sexual orientation is not listed and enter it in the field below. Important: This checkbox and field can be used in addition to specifying entries from the list. Click OK to close the Additional Gender Information window.
Birth	Select the patient’s date of birth.
ID	Enter the patient ID number. Note: The number may be partially masked with asterisks if configured by the institution. Example: A social security number or number set by the institution. Note: The ID must be unique if Patient Options window > Patient Entry > Patient ID is Unique checkbox is selected. If the patient is a policy holder, the ID may also display in the Guarantor tab > Guarantor ID field and in the Insurance tab > Subscriber field.
Marital	Select the patient’s marital status.
Student	Select the patient’s student status. Note: Being a student affects a patient’s insurance coverage.
Language	Click the ellipsis to select the patient’s preferred language.
Race/Ethnicity...	Click the button to select and display the patient’s race and ethnicity.
Home Address	Enter the patient’s full address in the available fields. Tip: If you complete the Zip field first, the City, State, Country, and County fields auto-populate.
Telephone	Enter the patient’s phone numbers. If used, the third field displays an extension number or descriptor.
Other Loc.	Enter a location or the type of number entered in the Other# field. Example: Another workplace number or a service number.
Home, Work, Mobile, Other / Time	Select a radio button to indicate the preferred contact method and enter the best time to contact the patient, e.g., after 3:00 PM.
Patient	Select the checkbox if the record is for a patient. Note: Non-patients can be searched for, but aren’t available in Scheduler, EHR, etc.
Emergency	Select the checkbox if the patient began as an emergency patient. Note: This is for reporting purposes and does not affect user access.
Special Needs	Select the checkbox if the patient is a special needs patient. Note: This may extend insurance coverage beyond usual age limits.
Policy Holder	Select the checkbox if the patient is a policy holder. Note: The checkbox is auto-selected if the person is a listed policy holder in Patient Info > Guarantor tab.
Status	Select the patient status: screening patient, a guarantor/policy holder, active, or inactive. Notes: If the status is set to Inactive, some actions are unavailable. If a patient changes from Inactive to Active, an existing recall is updated to the current date or a default recall is added for today. Tip: Many institutions set brand new patients to Screen. They don’t set the status to Active until after the first appointment.
End Date	Select the date the account was closed, if applicable. Note: If a future-dated end date is present, you can still access or enter treatments for this patient.
Account	Select a patient account status.
Open Date	The auto-generated date the account opened.
Patient Types...	Click the button to select a patient type and set the access for different levels for each patient type.
Alt Chart	Enter the patient record’s alternate chart number. Note: Some institutions use this number to find the chart in specialty clinics; others record the chart number used prior to axiUm.
Chart Area / Box#	Enter the chart storage area and storage box number.
Email	Enter the patient’s email address. Note: axiUm validates email addresses according to RFC standards. If the address is in an invalid format when you click Save, an error displays.
Create PatientAccess... / PatientAccess Info...	Click the button to display the PatientAccess Info. window and manage the patient’s PatientAccess account, including adding specific forms and adding representatives. Notes: This is only enabled if the PatientAccess module was purchased. An error displays if the email address in the Email field is in an invalid format.
Providers..., Managers..., Faculty...	Click the buttons to display the Provider Assignments, Manager Assignments, or Faculty Assignments window and manage assigned providers, managers, and faculty members for the patient.
[text box]	Displays all assigned providers, managers, and faculty members.

4. Complete the Codes tab fields as necessary.
Codes Tab Fields



Field	Description
Fee / Bill Pt Fee	Select a fee schedule code that will override an existing fee schedule and select when to use the selected fee schedule. Notes: This field may be applicable if the patient doesn’t have coverage. Only complete this field if the situation warrants. The Bill Pt Fee field is only enabled if the Fee field displays a code.
Discount	Click the ellipsis to select the discount group that applies to the patient and reduces patient fees by a set percentage.
School / Health Unit	Click the ellipsis to select the patient’s school and enter the district health unit.
Pref. Appt	Enter the patient’s preferred appointment time.
Bank Acc#	Enter the patient’s bank account number. Note: Some states may garnish overdue fees. If this is the case, fees are deducted from this bank account.
Active Date / Date Closed	Select the date on which the patient record became active and the date will close, if applicable. If the patient record is still active, this field must be blank. Note: These dates are used for reporting purposes.
Tax Exempt	Select the checkbox if the patient is exempt from taxes.
Appointment Fee Exempt	Select the checkbox if the patient is exempt from failed or cancelled appointment charges.
Accept Assignment	Select the checkbox if the institution accepts insurance from the patient. Note: This option is also set from Maintenance > Office > Practices.
Send Statements	Select the checkbox if statements should be sent to the patient. Note: If deselected, the patient is excluded when axiUm generates a batch of statements in the Info Manager module.
Free Access	Select the checkbox if the patient’s chart is accessible to all providers.
Require Treatment Consent	Select the checkbox if a signed consent form is required before treatment is performed. Note: This works in conjunction with the Maintenance > System > System Options > Require Consent checkbox.
Release of information on file	Select the checkbox if the patient has a release of information consent form on file that authorizes the institution to contact insurance companies with claims. Note: If your state doesn’t require this consent, it doesn’t need to be a required field.
No Chart Locks	Select the checkbox if chart locks in the Chart Tracking Locks window do not apply to the patient.
Paper Chart	Select the checkbox if the patient has a paper chart. Note: If deselected, an error message displays when a user manually requests a paper chart, and areas that auto-request a chart are blocked.
Patient Alerts	Enter up to five patient alerts that appear on the Patient Card. Alerts are not clinical in nature but offer important additional patient information. E.g., Deaf.
Office Codes	Enter up to five office codes that appear on the Patient Card. Office codes are not clinical in nature but offer patient administration information. E.g., Cash Only.
Custom Fields	Enter up to 10 customized field categories and their selected entries that are used for reporting and research. E.g., Home Clinic, Referral Source, Language.
Custom Info	Enter identifying information for up to five customized fields. E.g., Driver’s License.
Needs...	Click the button to view the Patient Needs window.
Ortho...	Click the button to view the Ortho Patient Information window.

5. Complete the Clinical tab fields as necessary.
Clinical Tab Fields



Field	Description
Last / First / Middle	Enter the emergency contact’s last, first, and middle name. Note: The fields can hold a maximum of 30 characters.
Phone# / Alt#	Enter the emergency contact’s main and alternate phone numbers, including an optional extension number or descriptor.
Address / City / State / Zip / County	Enter the emergency contact’s full address. Tip: If you complete the Zip field first, the City, State, Country, and County fields auto-populate.
Same as Pt	Click the button to make the emergency contact’s address the same as the patient’s address.
Relation	Select the emergency contact’s relationship to the patient or enter a free-text option. Note: If you enter a non-standard relationship, you will be asked to confirm you want to proceed.
Patient Physician	Click the ellipsis to select the patient’s physician.
Patient has Picture	Select the checkbox if the patient has a picture. When selected, the Capture... and Browse... buttons are enabled.
Capture...	Click the button to display the Capture Picture window. Note: Previously only TWAIN scanners were available, but any integrated or USB-connected web cams are now supported.
Export...	Click the button to select a location to save the photo file. Note: The image file is saved in the same format used for the original photo.
Browse...	Click the button to locate an image stored on a local or network drive.
Referrals	The left-side field displays physicians or sources that referred the patient. The right-side field displays physicians or sources this patient has been referred to.
By...	Click the button to display the Referred By window and add a referral to explain how the patient was referred to the institution.
To...	Click the button to display the Referred To window.

6. Click Save.

The patient record is saved and the Guarantor, Employer, and Insurance tabs display.

Note: If any required fields are incomplete, they display in pink and the record cannot be saved until they are complete.

Once the patient record has been saved successfully, you can specify a guarantor, specify an employer, and specify a benefit plan as necessary.

A guarantor is a person responsible for the patient. A patient can have multiple guarantors. By default, a person is their own guarantor, but other guarantors can be added, if necessary.

Example: A parent or guardian is usually a child’s guarantor.

Note: The same person can be guarantor for a maximum of 21 patients.

The Guarantor tab contains fields related to the patient’s guarantor(s). This includes basic information such as names, demographics, address, status, contact information, and additional information.

When a patient record is created, the patient is selected as their own guarantor. If the patient doesn’t need an additional guarantor, you can skip to 1. If the patient can't remain their own primary guarantor, then you must specify the guarantor record(s).

Notes:

• If the guarantor record is the patient, many fields are disabled and cannot be modified from the Guarantor tab.
• Guarantors don't have to be patients in the clinic, but they must have their own their record in axiUm that contains their name and pertinent details.

To specify a patient guarantor:

Warning: Before you create a new guarantor record, search for the guarantor name to ensure they are not in axiUm.

1. With the Patient Info window open, click the Guarantor tab.



Note: By default, the patient’s information displays in this tab and the This is the Patient checkbox is selected.

2. Click the Clear Data () icon to reset the fields in the tab and enable the Select Guarantor button.
3. Search for the guarantor.
1. Click Select Guarantor to display the Select Guarantor window.

2. In the text field, enter the last name and press Enter.

4. Add the guarantor.
• If the guarantor is listed in the results:
Add the Existing Guarantor
1. Double-click to select the name and close the Select Guarantor window.

Tip: If the checkbox next to the guarantor is selected, the guarantor is a patient in axiUm.

2. Click the Add a new Record () icon.

If the guarantor has an insurance policy, the following question displays.



• If the patient is covered under this guarantor’s insurance, click Yes.
• If the patient isn’t covered under this guarantor’s insurance, click No.
• If the guarantor is not listed in the results:
Add a New Guarantor

1. Close the Select Guarantor window.
2. Complete the Guarantor Information, Address, Personal, and Status section fields as necessary.
Guarantor tab fields



Field	Description
This is the Patient	Select the checkbox if the guarantor is the patient.
Select Guarantor...	Click the button to select a guarantor from the Select Guarantor window.
Relationship	Select the guarantor’s relationship to the patient. Note: When the This is the Patient checkbox is selected, the Relationship field is set to Self and should not be modified. Tip: Do not edit the Self guarantor record other than to change the Primary Guarantor, Secondary Guarantor or Policy Holder fields.
Title / Last / First / Middle / Preferred	Enter the guarantor’s title, last, first, middle, and preferred names. Note: The fields can hold a maximum of 30 characters.
Phone# / Alt Phone#	Enter the guarantor’s main and alternate phone numbers, including an optional extension number or descriptor.
Email	Enter the guarantor’s email address. Note: axiUm validates email addresses according to RFC standards. If the address is in an invalid format when you click Save, an error displays.
Guar. ID	Enter the guarantor’s ID number. Notes: The number may be partially masked with asterisks (***) if the institution has been configured to preserve confidentiality. If the patient is their own guarantor, axiUm uses the entry from Personal tab > ID field by default.
Send Statements	Select the checkbox if the guarantor should be included in the guarantor statement report. Note: The field is enabled and selected by default when the selected guarantor is a non-patient but disabled if the guarantor is a patient.
PatientAccess Info...	Click the button to display the PatientAccess Info window. Note: An error displays if the email address in the Email field is in an invalid format.
Address / City / State / Zip / County / Country	Enter the guarantor’s full address in the available fields. Tip: If you complete the Zip field first, the City, State, Country, and County fields auto-populate. Note: If the guarantor resides in a country other than the institution’s country of address, only complete the Country field.
Same as Pt	Click the button to make the guarantor’s address the same as the patient’s address.
Status	Select the guarantor’s status at the institution. Note: The Guarantor/Policy Holder status is specifically for guarantors who are not patients at the institution.
Sex / Birth	Select the guarantor’s gender and date of birth.
Marital	Select the guarantor’s marital status.
Language	Select the patient’s preferred language.
Patient Types	Click the button to display the Patient Types window.
Emancipated Minor	Select the checkbox if the patient is an emancipated minor and is legally their own guarantor.
Policy Holder	Select the checkbox if the guarantor has an insurance policy. Note: If selected, the guarantor’s name populates in the Insurance tab > Policy Information > Subscriber > Holder drop-down list.
Primary Guarantor	Select the checkbox if this is the patient's primary guarantor. Note: The guarantor is not necessarily a policy holder.
Secondary Guarantor	Select the checkbox if this is the patient's secondary guarantor. Note: The guarantor is not necessarily a policy holder.

3. Click the Add a new Record () icon to add the guarantor to the list.

axiUm auto-fills some fields and sets the Guarantor Status to Primary.

The Employer Tab allows you to record the patient’s employment information. It contains fields related to the patient’s employer(s). This includes information such as the employer name, occupation, address, and contact information.

Note: Some institutions choose to skip adding the employer information. You can still add insurance without adding employer information.

If configured by your institution, this can be used to link the employer’s insurance plan to the patient.

If a patient has multiple employers, you can set one as primary and add other employers afterward.

Children, self-employed patients, and patients who have contracted insurance (such as Medicaid) do not require employer information. For these patients, skip to Specify Benefit Plans.

To specify a patient employer:

1. With the Patient Info window open, click the Employer tab.



2. Complete the fields as necessary and click the Add a new Record () icon to add the employer entry to the list below.
Employer Tab Fields



Field	Description
Primary Employer	Select the checkbox if this is the patient’s primary employer. Note: If they have other employers, this checkbox must be deselected in those employment records.
Employer	Click the ellipsis to display the Employer List window and search for the employer. If listed, double-click the correct entry to select and close the Employer List window. If not listed, click the Add a new Record () icon to display the Employer window. Complete the fields as necessary and click OK to close the Employer window. From the Employer List window, search for and double-click the new entry to close the Employer List window.
Occupation	Click the ellipsis to display the Occupations window and search for the job title. If listed, double-click the correct occupation entry to close the Occupations window. If not listed, in the Occupation field, enter a new title and click the Add a new Record () icon. Double-click the new entry to close the Occupations window.
Phone #	Enter the employer’s phone number.
End Date	Enter the date the employment ends (if applicable).
Note	Enter any additional information.

Important: Given the complex nature of benefit plans, we do not recommend adding benefit plans from the Patient Info window > Insurance tab. We recommend that your institution disable all fields in the Insurance tab except for the Link to Insurance Benefit Plan () icon so that only users with insurance permissions can create benefit plans. Even then, we recommend you add plans via the Maintenance module to prevent benefit plan duplicates.

The Insurance Tab contains fields related to the patient’s insurance plans(s). This includes the benefit plan information such as the insurance provider, employer, coverage details, patient payment details, and policy information, such as subscriber details and family balance.

A benefit plan provides coverage for a variety of medical and dental procedures. Insurance companies provide coverage to patients through benefit plans that are private (purchased by the individual), provided by an employer or provided through government programs.

Note: Many people obtain coverage through another person’s insurance coverage (spouses, children, etc.)

Depending on the type of plan, the coverage may be for full or partial, and the patient may be responsible to pay deductibles, and/or any amounts not covered by their insurance. Some plans contain multiple people with the same coverage. The benefit plan has the same insurance company, group number (the benefit plan ID) and coverage, but each person on the plan has a different subscriber number.

In the cases of employer-provided plans, many companies provide insurance benefit plans that covers some or all of their employees’ dental procedures and expenses. Some companies have multiple benefit plans that provide varying levels of coverage linked to them. This is more common for companies in multiple states/provinces because insurance providers often vary by region.

When an employee with a company benefit plan becomes a patient, and has their employer added to their record, you can add the employer’s insurance to the patient.

Tips:

• Before you link an employer’s insurance to a patient, confirm the plan exists in the employer record.

• Depending on your institution's workflow, employer-provided insurance may be linked from the Employer tab. However, if an employee benefit plan has been linked to a patient, its details are available from the Insurance tab.

To specify a benefit plan:

1. With the Patient Info window open, click the Employer or Insurance tab.
2. Click the Link to Insurance Benefit Plan () icon to display the Select Benefit Plan window and search for the appropriate benefit plan.
• If listed in the results, double-click the entry and close the Select Benefit Plan window.
1. When prompted, click Yes to confirm you want to add a policy to the plan and display the Policy Information window.

2. From the Policy Information window, complete the following fields and click OK.

Policy Information fields



Field	Description
Holder	This field indicates the policy holder (in most cases, the patient). Select the correct policy holder.
Subscriber#	Enter the subscriber/patient number for this plan.
Start Date	Enter the date the coverage takes effect.
End Date	Enter the date (if known) that the policy coverage will end.

• If the benefit plan is not in the Select Benefit Plan window, close the window.
1. From the Insurance tab, complete the fields as necessary and click the Add a new Record () icon.

Warning: Information added under the Benefit Plan Information section affects all policy subscribers on the plan; information added under the Policy Information section affects only the individual subscriber.

Benefit Plan Information fields



Field	Description
Insurance	Click the ellipsis to select the insurance company that holds the benefit plan.
Coverage...	Click the button to open one of the following windows: Benefit Plan Coverage: Displays if the coverage is unique to this benefit plan. Linked Coverage Template: Displays if the benefit plan uses a generic coverage template that is shared between multiple benefit plans.
Group / Division	Enter the policy’s group number and division number.
Employer	Select the employer that provides the benefit plan.
Description	Enter a short description of the policy coverage.
Coverage	Enter the coverage type.
Contract	Click the ellipsis to select a contract policy code if the plan is a contract plan.
Fee Sch	Click the ellipsis to select the fee schedule code used for this benefit plan. Note: This defaults to the code assigned in the Insurance Company window > Default Fee field. It can be changed after the insurance policy is added.
Override...	Note: This button is only enabled if the Contract field is set to a contract policy code. Click the button to display the Contract Fee Schedule Overrides window and select an override to the contract's fee schedule for specified providers. Note: Previously, this button was labeled Specialists....
Plan Type	Select the plan type. Note: This defaults to the code assigned in the Insurance Company window for the company selected. It can be changed after the policy is added.
Forms To	Select where claims must be submitted: Insurance: to the patient’s insurance company. Patient: to the patient. Employer: to the employer. Office: to the institution’s office. Note: Use Office if your institution has its own insurance company. axiUm can also handle grants and discounts that are not insurance plans at the institution’s office.
Can have multiple subscribers	Select the checkbox if others can subscribe to the benefit plan. Note: If the plan is provided by an employer, it must be accessible to other employees from the same company.
Charge Deduct and Pt Charge	Select the checkbox if patients can be charged deductibles and amounts not covered by insurance. Tip: Patients on contract plans will likely have this checkbox deselected.
Co-pay	Enter an applicable fee charged once per date that is part of the total fees owed and must be paid by the patient. Note: Many institutions use this field to discourage policy holders from over-using their plans.
Visit Fee	Enter an applicable visit fee charged once per date, that is part of the total fees owed and must be paid by the patient. Note: This field is visible if the insurance company charges patient visit fees. This is enabled from Maintenance > Insurance tab > Insurance Companies > Advanced button > Charge Patient Visit Fees checkbox.
Override...	Click the button to display the Visit Fee Overrides window and set different office visit fee amounts for different provider types. Note: This button only displays if the Visit Fee field displays.
[Patient] Deduct	Enter the amount paid by the patient before their plan coverage begins and how often it is paid.
[Patient] Limit	Enter a limit option and the patient’s yearly coverage limit for this policy, if applicable. Note: If No is selected, the text field is disabled.
Yr End ___ Month / __ Day	Enter the month and day that represent year end. Example: 6, 30 represents June 30
[Family] Deduct	Enter the deductible amount paid by the family. Note: If entered, the Limit field under Policy Information is enabled and auto-filled.
[Family] Limit	Enter a limit option and the family’s yearly coverage limit for this policy, if applicable. Note: If No is selected, the text field is disabled.
Change Date	Enter the date the policy information was last changed.
Assignment	Select the checkbox if the institution accepts assignment from the company. Note: This field defaults based on the insurance company setup. It can be changed after the policy is added.
Write Off	Select the checkbox if patients may have their charges written off when the insurance company's procedure coverage is higher than the amount charged by the clinic. Note: The insurance company is billed their amount, but the patient portion is written off automatically. Example: If the regular fee amount is $40, and insurance will cover 60% of $100, the insurance company is billed $60 and the patient billed $0. In most cases, an agreement between the clinic and insurance company is required to use this option.
Sig Req’d	Select the checkbox if the insurance company requires policyholder and patient's signatures on claim forms. Notes: If deselected, the claim form prints Signature on File in the signature areas of the form. The checkbox default is based on Insurance Company Advanced Options window > Signature Required checkbox. You can change this field after the policy is added.
Start Date / End Date	Select the date on which the benefit plan becomes effective for all subscribers, and ends, if applicable.

Policy Information fields



Field	Description
Holder	Select the policy holder’s name.
Subscriber#	Enter the policy holder’s subscriber ID. Note: The number may be partially masked with asterisks if the institution is configured to preserve confidentiality.
Start Date / End Date	Select the date on which the individual subscriber’s policy becomes effective, and ends, if applicable.
Deduct	Enter the family deductible balance still owed for this policy. Note: This field is enabled if the Family section > Deduct field is populated.
Limit	Enter the balance of the family's coverage limit for this policy.

Sometimes you must create a patient record that has many of the same details as another patient record.

Example: You must create a patient record for a family member that has the same last name, address, contact information, and emergency contact information details.

It is much faster and easier to copy an existing patient record and modify differences instead of making a brand new one.

When you copy patient records, axiUm copies the last name, address, and phone number, and requires confirmation to copy emergency contact and insurance information.

Note: This does not copy any clinical information.

Warning: To avoid data issues, ensure that no one will access the original patient record during the copy process.

To create a copied patient record:

1. Open the Patients module and select the patient to copy from.

Note: If you can choose between a policy holder and a dependent with insurance to copy from, select the dependent. This prevents the new patient from being added as another policy holder on the same policy.

Example: If a mother and child attend the same dental institution and you must create the father’s patient record, copy the child’s record.

2. Click the Patient Copy () icon to display the Copy Patient Question window and click Yes.



If the source patient is a policy holder or is associated with a policy holder, the Select Policies window displays.



Note: If the source patient is a policy holder, the policy is marked with an * symbol.

3. If applicable, review the Select Policies window and complete any of the following actions:
• If the new patient will be a policy holder, select a policy with an (*) and click OK.
• If the new patient won’t be a policy holder, don’t select a policy and click OK.

Note: If the new patient should have an insurance policy, you must add the benefit policy holder to the record later.

• If the new patient will be a dependent of a policy holder, select a policy without an (*) and click OK.

If the source patient has Emergency Contact information entered, a Copy Emergency Question window displays.



• If the patient should have the same emergency contact information, click Yes.
• If the patient shouldn’t have the same emergency contact information, click No.
4. From the displayed Patient Info – Copy window, complete the fields as required, click Save, and close the Patient Info window.
5. When prompted with the Select Patient Question window, click Yes to display in the selection list or click No to continue without displaying in the list.



6. If necessary, add a guarantor, employer, or additional benefit policy.