Need help with Risk Management Question

I am writing a Risk Management paper for school. The Risk problem is a current issue in my facility. I need to know if anyone else has an issue with patient identifiers? Problem: when patient's come from the surgeon's office or when items are faxed, the items (consents, orders, H&Ps) don't always have enough or any patient identity. We are trying to implement the requirment for every item from the surgeon's or md's office to have at least 2 pt identifiers: Name and date of birth.

What do some other facilities require?
Help, paper due Monday 9/27/10.