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Tips for Proper Call Documentation at Your Practice

You take the time to carefully document patient visits; make sure that same care is taken to document patient phone calls.

You take the time to carefully document patient visits; make sure that same care is taken to document patient phone calls.

Like other documentation, the common rule when it comes to call documentation is that if it is not documented, it did not happen. Therefore, every clinically relevant telephone call should be documented. 

Clinically relevant calls include those pertaining to: symptoms, medications, disease process and management, test results, and patient education. 

It is recommended that you establish call documentation protocols for your practice. Set protocols allow for clear and timely documentation that can help in avoiding disagreements over what was said, when it was said and why it was said.

The following tips can help establish call documentation protocols at your practice:

1. Be proactive regarding call documentation by developing a policy and corresponding procedures.

  • Train staff members in telephone protocols and authorize them to interrupt the provider as necessary
  • Provide nonclinical personnel with guidelines to appropriately respond to emergency/urgent care concerns

2. Be specific.

  • Record the content of the call in the patient’s record
  • Include any advice/instructions provided and the patient’s understanding of that information 
  • Include the name of the staff person who took the call in addition to patient requests, concerns and issues
  • Document all follow up conversations and calls concerning previously discussed problems, recommendations and test results in a timely manner
  • Document calls and conversations with family members (including the name of the person who called and their relationship to the patient) 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
    • Advise the patient of approximately when they may receive a call back, from whom and confirm the number to reach them at that time.

3. Periodically review the telephone responses and documentation to bring to light situations in which additional staff training or policy revisions may be required.

You should never feel that call documentation clutters your records. Instead, consider call documentation to be an essential opportunity for documenting your communications with patients. This will help lead to a complete and accurate clinical record.

If you have questions about documenting calls, as a policyholder, contact NCMIC's Claims Advice Hotline.

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