Tips for Documenting Calls

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

Posted in Risk Management on Friday, June 1, 2018

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

It is recommended that you establish call documentation protocols for your practice. Established protocols allow for clear and timely documentation that can help avoid disagreements over what was said.

Here are tips to establish call documentation protocols at your practice:

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

• Train staff members in telephone protocols and authorize them to interrupt you as necessary
• Provide any nonclinical staff with guidelines to appropriately respond to urgent care concerns

Be specific.

• Record the content of the call in the patient’s record
• Include any instructions provided and the patient’s understanding of that information
• Include your name—or the name of the staff member who took the call—and information about the patient’s requests, concerns and issues
• Document all follow-up conversations and calls concerning previously discussed problems, recommendations and test results
• Document calls and conversations with family members (including the name of the person who called and their relationship to the patient)
• Rather than ask patients to call back later, advise them of when you will be available to return the call and confirm the number to reach them

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

Call documentation is an essential opportunity to document communications with patients, leading to more complete and accurate clinical records. (See related article.)