Documenting telephone encounters should be treated with the same level of importance as documenting in-person visits. Telephone conversations, particularly those that occur after-hours, are a major area of liability risk. The advice given to a patient over the telephone often becomes crucial to his or her continued care. It may also be vital in the event of a medical malpractice claim. Therefore, all telephone conversations with patients, regardless of when they are received, should be documented in the patient’s medical record - both for continuity of medical care and for the defense of a potential malpractice claim. Documentation should provide a clear picture of what information was given to the patient, including follow-up instructions and information specifying when to seek emergency care. Documentation such as “spoke with patient” is not as complete as a detailed note and may hinder continuity of care and defensibility in the event of a claim.
In most cases, undocumented conversations become a “he said/she said” dispute and prolong a claim’s resolution. A note recorded in the medical record on the front end can save a lot of heartache on the back end. In many cases, contemporaneous documentation of the provider’s instructions would have greatly aided in the defense of a malpractice claim against the provider.
Contemporaneously documenting care is particularly crucial when documenting after-hours. Calls from a patient outside of normal office hours are often of a serious nature. Without contemporaneous documentation, the physician must rely on memory to recall the advice or recommendation given. At a minimum, the following types of phone calls need to be contemporaneously documented in the medical record:
- All phone calls in which test results are reported to patients, noting if the patient was advised to return or seek other medical attention.
- All phone calls in which the patient is advised to return or seek other medical attention, including instructions to go to the emergency department.
- All phone calls in which a patient requests medical advice or prescription refills.
To assist in the documentation of relevant phone call information, SVMIC provides phone call record forms free for members. Request them here.
