Telephone Call Documentation

How does your office handle telephone messages from patients?  Are they recorded in a telephone log?  Added to the chart?  How are physicians notified about the call?  These are important questions because they effect patient outcomes and patient safety. 

Staff should be trained to immediately transcribe telephone calls and voicemails in a telephone log including name, date, time, contact number and a summary of the issues. The gold standard is an integrated Electronic Medical Record (EMR) and telephone messaging system that documents the call in the patient’s record and pushes an alert to the physician.  An integrated system is a great investment; it is efficient for staff message entry, provides prompting for complete data collection, promotes timely documentation and assures physician notification. 

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If your office does not have an integrated EMR/telephone messaging system, then pre-printed phone record pads are recommended with a defined process for notifying the physician.  Forms prompt staff to request necessary information and keep it organized.  There should be a section for confirming that the physician was notified.  There should be a corresponding section for the physician to indicate his/her response, such as for renewing a prescription or making a referral. 

Answering services should have a defined script for taking after hours calls.  You and your staff also need a defined process for assuring prompt documentation and response to calls received by the answering service calls. 

Telephone calls for prescription refills, test results, basic triage or other care related items require additional attention and should be documented in the SOAP Note section of the chart.  Telephone calls that are remotely handled by the physician (ie. outside the office and with no access to the patient chart) are easily overlooked but must be documented promptly.  Whether via dictation, transcription or handwritten note, physicians must have a defined process and written policy for ensuring that these out-of-office communications are documented in the patient chart.

Written policies and defined processes for proper documentation of telephone calls are also necessary for covering physicians and temporary staff that may not be as familiar with the patient and would otherwise have no way of knowing about the call. 

Consistent, reliable call processing and documentation is also important for patient satisfaction.  Patients reasonably expect that their physician know that they called when they come to an appointment.  When a physician is not aware of a patient’s call, the patient loses confidence and trust.  He/she may feel that the office is disorganized, that the staff does not care or that what they say is not important to the physician.

If you have any questions about telephone documentation or any other Risk Management issues, please call the CAP Hotline at 800-252-0555.

 

Authored by Michael Valentine, JD
CAP Senior Risk Manager

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This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.