Documenting patient telephone conversations is essential to ensuring safe and effective care in any medical practice. Accurate and timely documentation enables the healthcare team to clearly understand the patient’s issues, the guidance provided, and the actions taken during both routine office hours and after-hours calls. This practice promotes continuity of care, minimizes the chances of miscommunication, and provides a dependable record in case any concerns emerge later. As these conversations often involve urgent symptoms, treatment recommendations, or instructions on when to seek emergency medical attention, proper documentation is critical, particularly if a medical malpractice claim arises.¹
In one case, a physician was on call after hours when she stepped out of a movie to return a patient’s call. Based on the patient’s conversation and slurred speech, the physician advised her to go directly to the emergency department (ED). The patient did not follow the physician's advice and suffered a massive stroke later that night. She subsequently sued the physician, alleging that she had not been told her condition was an emergency. The patient also stated that a friend who was with her that evening did not hear the physician instruct her to go to the ED either. The physician did not document the call until the next morning after learning that the patient had been hospitalized with a cerebrovascular accident (CVA). Because the documentation was created after the fact, it was viewed as self-serving and provided little support for her defense. Had she made a timely written note documenting the conversation, her recommendation, and the time of the call, whether on a notepad or in a secure electronic note, that record could have significantly strengthened her case.
In another case, a mother claimed that she had called an urgent care center four times and that no one advised her to take her child to the ED. However, the urgent care staff had documented all telephone calls. A review of the center’s records, along with telephone company records, showed that the mother had called only three times, and the documented calls did not reflect urgent or emergent concerns. The defense prevailed because the contemporaneous documentation provided a clear and credible record
of what had occurred.
Modern electronic medical records (EMRs) frequently include built-in telephone messaging tools that facilitate quick data capture, timely documentation, and notifications to physicians when necessary. Additionally, these systems often offer remote access, enabling physicians to review and respond to messages promptly from virtually any location.
Recommendations for Protecting Yourself With Proper Documentation
- Set up call documentation protocols:
- Take a proactive approach by creating a clear policy and detailed procedures for telephone call documentation.
- Train your staff on telephone protocols and empower them to interrupt clinicians when urgent situations arise.
- Provide nonclinical staff with specific guidelines on how to handle urgent patient inquiries.
- Regularly review your telephone response procedures and documentation to identify opportunities where additional staff training or policy updates might be needed.
Be thorough and precise in your documentation:
- Record the details of the call in the patient’s medical record.
- Note any instructions given and confirm the patient’s understanding.
- Include the name of the person handling the call—whether a clinician or a staff member—and document the patient’s requests, concerns, and issues.
- Maintain records of all follow-up calls or conversations related to previously discussed concerns, recommendations, or test results.
- Document interactions with family members, including the caller’s name and relationship
to the patient. - Rather than asking patients to call back later, inform them when you will be available to return their call and verify the best number to reach them.
Effective call documentation is a vital tool for capturing patient communications and contributes to more complete, accurate, and defensible clinical records.²
Include critical information in the call record:
Attach the call note to the patient's record and include the following information:
- Patient Name
- Caller
- Time
- Reason for Call
- Recommendations
- Current Medications
- Prescription
- Allergies
- Pharmacy
- Pharmacy Phone Number
Dona Constantine, RN, BS, is a Senior Risk Management and Patient Safety Specialist. Questions or comments related to this article should be directed to DConstantine@CAPphysicians.com
References:
¹Risk Management Handbook for Healthcare Organizations Sixth Edition, Vol 1; The Essentials by Roberta Carroll. American Society for Healthcare Risk Management. 2011. “Telephone Calls and Advice in Physician Office Practices,” pp.354-355.
²Gellis-Server, Jackie. “After-hours Telephone Documentation.” Cooperative of American Physicians, Risk Management Department, 2009.