In order to maintain a complete and accurate medical record, it is essential to document all clinically relevant telephone calls. Clinically relevant calls include calls pertaining to symptoms, medications, disease process and management, test results and/or patient education.

Posted in Risk Management on Tuesday, January 12, 2016

At PSIC, we talk with many physicians who call our Risk Management Hotline about the importance of call documentation protocols in his/her medical practice. Following is a question recently asked and our response to the physician.

Q:  Call documentation “clutters” my electronic health record (EHR). Is it really necessary to document every call I receive from a patient?

A:  Yes. To maintain a complete and accurate medical record, document all clinically relevant telephone calls. Clinically relevant calls include calls pertaining to symptoms, medications, disease process and management, test results and/or patient education. 

Here are a few tips for documenting phone calls in your medical practice:

• Train staff members in telephone protocols and authorize them to interrupt the provider as necessary. 
• Provide non-clinical personnel with guidelines to appropriately respond to emergency/urgent care concerns.
• Develop procedures to address and document patient requests, concerns and issues in a timely manner.  
• Document all clinically relevant telephone encounters and include the name of the staff person. This includes follow-up conversations and calls concerning previously discussed problems, recommendations, and test results.  
• Be specific. Record the content of the call in the patient’s medical record, including any advice/instructions provided and patient understanding. Clear, timely documentation of your communications avoids disagreements about what was said and to whom.   
• Document calls and conversations with family members and relay this information to the provider or designated staff member.
• Rather than having a patient call the provider back, have the provider or designated staff member return the call.

Be proactive regarding call documentation. Don’t consider call documentation “clutter”; instead consider call documentation an essential part of documenting your communications with patients leading to a complete and accurate medical record.