As risk managers, we stress that all clinically relevant calls to the practice should be thoroughly documented. However, when calls are received after hours, call documentation can be less than optimal. Even worse, sometimes nothing is documented at all.

Posted in Articles on Wednesday, September 5, 2018

As risk managers, we stress that all clinically relevant calls to the practice should be thoroughly documented. However, when calls are received after hours, call documentation can be less than optimal. Even worse, sometimes nothing is documented at all.

What is the best way to handle after-hours call documentation to enhance patient safety and improve your defensibility in a claim? The first step is to develop an after-hours call documentation and tracking policy. 

The purpose of this policy is to consistently document relevant telephone calls received when the office is closed. Consider including the following procedures in your policy:

• Every morning, the answering service will provide a list of calls received after hours.
• The office manager, or a designated individual, will cross reference and reconcile the answering service list with the provider on call to confirm the calls’ receipt and actions.
• Call documentation should be done first thing in the morning while the information is still fresh. 
• If the call was dictated by a provider, it should be transcribed and then reviewed by the provider with evidence of his or her approval (e.g., initialed and dated).

For ease and consistency, have an after-hours contact form that allows the provider to simply fill in the information. Be sure to include:

• Date and time the call was received 
• Date and the time of the return call
• Caller’s name and telephone number
• Patient’s name, if not the caller, and his or her relationship to the patient
• Reason for the call (e.g., symptoms, complaint, duration, home remedies)
• Medications taken, including prescriptions, over-the-counter drugs, and supplements and herbal remedies
• Known or suspected allergies
• Brief review of medical history (e.g., pregnancy, high blood pressure, alcohol/drug abuse)
• Diseases or conditions
• Initial tentative diagnosis
• Advice and/or instructions provided
• Drugs prescribed, including their name, quantity, dosage and instructions
• Drug information and education provided
• Name and phone number of the patient’s pharmacy
• Warning symptoms that require immediate attention

For more information and guidance about this topic, please contact us our Claims Advice Hotline.