The Keys to Documenting Phone Calls

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The Keys to Documenting Phone Calls

By Cliff Rapp, LHRM,
Vice President of Risk Management FPIC

The most important phone call a physician ever receives may be the one you or your staff forgets to document. In today’s legal climate it has become even more important to document all medically relevant phone calls. All phone conversations need to be documented in the patient’s chart regardless of whether the call is received by you or your staff. Your office should have an established procedure for dealing with all calls. Failing to document a call is tantamount to forfeiting evidence in the event a defense become necessary.

When a patient calls your office with a problem, have your staff document the phone call in the patient’s chart. Be sure they include important details of the conversations, including the time and date that the call was received, who called, the person who received the call, when the call was returned to the patient, and what was discussed. In addition, vital patient information and the condition or clinical status of the patient should be noted at that time.

It does not matter what your office procedure happens to be, what matters is that the phone call gets documented in the patient’s chart. Without documentation, in the event of a claim, it is extremely hard to defend details of discussions and specific instructions. In most cases, if a phone call is not documented and a claim is made and goes to court, it becomes your word against the patient’s word. Without documentation, the patient’s memory may carry more credibility than that of you or your staff who may have seen 20, 30, or more patients that day.

Remember to treat after-hour calls the same as any telephone conversation. If you are on-call you may want to consider establishing a procedure for these phone calls to be documented in the patient’s chart as part of the communication process. You may want to consider designating one staff person to follow-up with these patients and the on-call physician. Be sure your staff documents the salient portions of each conversation and what treatment was rendered to each patient. Protocols should also ensure that the communication loop is completed such that each patient receives a follow-up call.

The following are suggested elements to include when documenting phone calls:

Date and time of the call
Patient’s name
Chief complaint or concern
Brief history
Assessment
Disposition/advice
Necessary follow-up by advice-giver
Symptoms that develop which require the patient to call back
Signature or other information to determine advice-giver
Date and time of call to the patient, if applicable