Could we and would we want to operate an office without the telephone? We know that miscommunication is the most common root cause of adverse patient events in the physicians' office setting and telephone encounters are an integral part of the overall management of the patient; however; without protocols and training, risks exist. The Risk Management Department at MAG Mutual Insurance Company receives many questions related to telephone procedures and telephone triage. We are also aware of several serious incidents in which non-clinical personnel answered patients' questions and were alleged to have given medical advice without training or protocol, ( i.e., allegedly "practicing medicine without a license"). There are many telephone scenarios which can lead to serious preventable incidents.
We believe that well developed protocols can guide office personnel to provide efficient work flow, safe patient advice and appropriate transfer of more urgent calls to the proper provider. Additionally, we recommend that all clinical practices develop a policy for responding to telephone inquires for information/medical advice/ diagnosis, including maintaining a log of all calls and documenting telephone communications in the medical record.
WHY?
Information given via telephone by a staff member who is neither trained nor licensed to perform that function may expose the practice to liability and the patient to harmful advice. Protocols should be in place delineating which calls must be transferred to the physician immediately, which calls may be returned by the physician at a later time, and which calls may be handled by another professional. With greater emphasis on the use of the telephone in the field of medicine, healthcare professionals should take steps to monitor and control the quality of telephone medicine. The attitudes of employees and physicians are crucial, whether talking face to face with someone or having a telephone conversation.
Remember telephone encounters make evaluation more difficult than face to face because telephone evaluation relies on verbal cues without the benefit of observation. It is imperative that office staff utilize a courteous, helpful, and professional manner when speaking with patients over the phone. If members of the professional staff are authorized to give telephone advice, written protocols should define the scope of the professional staff member's authority to give telephone advice. Conflicts related to triage, confidentiality, etiquette, and documentation will be reduced by following well-designed telephone protocols and policies.
Lack of documentation of telephone communication is also another area of liability exposure for the physician's practice. Poor documentation of telephone contacts can negatively impact the defense of a medical malpractice claim. Any telephone interaction that is not documented can become "the patient's word against the staff's or physician's word". Therefore, documentation of these encounters is critical for continuity of care and defending allegations of substandard care.
TELEPHONE ENCOUNTERS
Telephone training for staff should include a list of questions to ask the caller and instructions for when to refer the call to the physician immediately. The physician will then know that if he/she is summoned to take a call, the patient has an urgent need. Document all calls involving a patient or family member. Documentation should include date, time, patient name, name of caller/relationship to patient, complaint, and advice given. Establish a reasonable time frame in which non-urgent calls are expected to be returned and if possible, build time into the physician's schedule to return calls. Always inform patients when they can expect a return call and periodically review telephone procedures and protocols with staff to ensure that telephone encounters are being appropriately managed.
TELEPHONE TRIAGE, ADMINISTRATIVE CALLS AND PRESCRIPTION REFILLS
For each call, complete a Patient Phone Inquiry form with a thorough list of symptoms that the patient is experiencing. Note on the form if the patient is requesting a prescription. Ask the patient: what is the nature of the problem, how long the problem has lasted, what medications they are currently taking (including non-prescriptions/over-the-counter meds) and any known allergies. Be sure to get a phone number where the patient can be reached today. Pull the chart, clip the Patient Phone Inquiry form to the front, and give the chart to the clinical triage staff member. Document the date, time, name of person calling and reason for the call, name of person taking the call, responsible persons, reference material used, referral to physician if appropriate, advice given, follow up plan/ disposition, staff responsibility, approval by medical director or supervising physician and rationale. Inform the patient that the nurse (or doctor) will be calling the patient back and the approximate time the patient can expect a return call. After it has been reviewed and signed by the medical staff, the form is permanently affixed to the medical record and becomes a part of the patient's chart.
Telephone triage requires accurate assessment without the benefit of a face-to-face encounter. If a patient is not able to provide an accurate description of general symptoms, guidelines will assist the staff in providing safe telephone assessment or determining if the patient needs to come in to the office. Referral triggers and forcing functions should be built into the system for non-clinical staff. Only professional staff with appropriate training should provide telephone assessments. Qualifications and training should be clearly defined in a job description for personnel who perform telephone triage.
If the patient or family member/caller seems overly anxious or is not satisfied with the advice given, or if the patient feels this is an urgent situation, a face-to-face encounter should be recommended. If a patient needs to be seen in the Emergency Department, the physician should phone the ED with a presumptive diagnosis or description of symptoms. Situations in which the patient should be told to hang up and dial 911 should also be identified. If the patient is unable to dial 911, the patient should be kept on the line while another staff member calls 911 on another line. All advice given over the phone should be documented. A follow-up call should be made to the patient to check on his/her status.
AUTOMATED CALL DISTRIBUTION SYSTEM?
A telephone answering service is preferable to an automated system for after-hours calls. If an automated system must be used, include instructions on what to do in case of emergency. Use an automated system only if you can ensure that messages are retrieved and responded to promptly and consistently. Include as few branches and choices in automatic call distribution systems as feasible and give the caller the option of speaking to a real person in case of emergency.
Consider using an answering service that comes recommended by other physicians. Review the answering service's procedures for handling physician office calls. Request periodic written reports or logs to review, and compare billings and message discrepancies. Place test calls periodically to evaluate the efficiency of the answering service. Give the service instructions/protocols for handling patient calls. The service should never screen calls involving medical problems. Provide the service up-to-date physician call schedules with accurate phone numbers. Make sure the service is aware of schedule changes and inform physicians how to let the service know of any last-minute changes. Provide the service with an emergency procedure in case the physician on call cannot be reached.
LEAVING A RECORDED MESSAGE ON THE PATIENTS PHONE
Obtain consent from the patient in regards to leaving messages on an answering machine as well who has authorization besides the patient to obtain clinical information. Be aware that someone other than the patient may access or overhear a recorded message, therefore, the caller should leave only a name, without his/her title, and request a call back... Never leave clinical information or advice on an answering machine and always document in the patient's record that a message has been left. Never assume the patient received your message. Institute a follow-up system for all calls made, and for serious concerns, send a posted letter, followed by a certified letter and retain copies in the patient's record.
AUTOMATED DIAGNOSTIC RESULTS REPORTING SYSTEMS
Several systems are commercially available and designed to streamline the process of reporting diagnostic results to patients. The physician leaves a recorded message in the system after results are known with further comments and further instructions for the patient. The patient calls the number and enters a PIN to listen to the message. This system eliminates the need to call repeatedly. Never leave messages with critical information or unexpected bad news. Those callers should be directed to telephone the office. Additional attempts to contact the patient must be made and documented.
In summary, telephone encounters are here to stay. We gain many advantages from this type of communication but must recognize the limitations and take appropriate actions to ensure safe high quality patient care.
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