How to Establish Effective Telephone Triage for Medical Practices

Executive Summary

Telephone triage is a crucial component in providing high-quality health care to patients. However, giving medical advice over the phone presents significant liability exposure because it is legally considered medical practice and requires assessing patients without the advantage of seeing them physically. Licensed and unlicensed professionals should be thoroughly trained to use standard protocols for answering patients’ calls and to know when they can address an issue or must delegate it to someone else.

Recommended Actions

• Only allow licensed professionals with the necessary training, such as registered nurses, to give medical and clinical advice.
• Educate staff on when unlicensed staff can answer nonclinical or non-urgent questions and when the call must be transferred to licensed professionals for telephone triaging and medical advice.
• Thoroughly train staff to use the protocols and regularly review and update them.

What is Telephone Triage?

Telephone triage is the process of evaluating a patient’s call to a physician’s office to determine the urgency of their medical issue, type of provider who needs to respond, and next steps for the patient. The person triaging must evaluate and record the patient’s symptoms while also checking their medical history and current medications to direct the patient to the appropriate level of care.

While telephone triage has many benefits, such as improving the quality of service and optimizing results, it also comes with risks, such as failure to treat or delayed treatment. Effective communication between a physician and a patient is crucial for maintaining a positive experience for the patient and for reducing liability exposure for the doctor. The healthcare organization handling telephone calls is responsible for triaging patients, scheduling appointments, refilling prescriptions and addressing patient questions either directly or by forwarding the call to someone with the appropriate authority.

Understanding Who Can Answer Calls

Because telephone triage requires an accurate evaluation of the patient’s needs without seeing the patient face-to-face, only licensed professionals with the necessary training should provide it. An unlicensed professional may answer a call and address nonclinical or non-urgent questions, but they must transfer it to a licensed professional if the patient seeks medical advice or the matter is urgent.

The American Nurses Association suggests that only registered nurses should provide telephone triage, but in some states licensed practical nurses and medical assistants who have received telephone triage training can answer patients’ calls to assess the level of urgency.

The licensed professional answering the phone determines whether the caller’s situation is urgent and whether it is a medical question that requires a physician or other employee of greater expertise to answer it. Qualifications for telephone triage should be clearly outlined in the job description of those who will perform it. In addition to the appropriate medical experience, a licensed professional must have sound judgment and decision-making abilities because they don’t have the luxury of physically assessing the patient.

Developing Guidelines for Unlicensed Professionals

Unlicensed professionals should not provide medical advice over the phone. Those who take initial calls must follow written triage protocols that include concrete examples of questions to ask the caller and suggested responses for nonclinical or non-urgent situations. Such protocols also should include an overview of the types of calls that require an office visit, a direct transfer to the physician for a more thorough evaluation, or a call to 911 for emergencies. Office staff must be given clear instructions and repeated training on situations that necessitate dialing 911.

Following triage procedures and passing along calls to licensed practitioners when necessary is critical for patient care and also to avoid liability issues. The supervising physician is responsible for all medical advice provided over the phone regardless of who gives it, and unlicensed staff who fail to follow scope-of-practice requirements create a common malpractice liability issue.

To further minimize this exposure, offices should create accurate job descriptions for all staff that highlight the importance of not acting outside their scope of practice. Qualifications and training should be clearly articulated in the job descriptions for those who will perform telephone triage.

Creating Triage Protocols

Medical offices should follow a telephone triage protocol that outlines a course of action for recommendations to make, documenting the telephone interaction, and making follow-up calls to patients. Triage procedures help licensed staff determine when and where patients should receive treatment, encourage standardized and superior care, and reduce risk. Employees should be thoroughly trained on how to use the protocols. It’s important to note that telephone triage and advice calls do not aim to produce official medical diagnoses, which should be made known to all staff and patients who call in.

Documenting Calls

All calls in which medical advice is given over the phone by a licensed professional should be thoroughly documented. Documentation should include date, time, patient’s name, caller name (if different from patient) and relationship to patient, complaints, how the injury occurred and the advice given. Also, information that helped eliminate certain issues, such as whether a patient has a fever, also should be documented, as should the reasons for any deviations from protocols.

Undocumented telephone triage and advice calls become the patient’s word against the staff. Even if a call seems unimportant or quick, an adverse outcome can result if the patient does not follow advice. Documentation of the telephone triage call should occur promptly to ensure accurate and detailed information.

Helpful Strategies for Telephone Triage

• Provide examples of issues that are likely to require an ER or office visit on the medical office’s website or in a welcome packet so patients have initial guidance on the most appropriate course of action.
• Train staff to check with the physician first if they have questions or concerns about protocols.
• Evaluate triage protocols regularly to confirm that they are being followed consistently and changed as needed.
• Train staff to treat all calls as serious and urgent until proven otherwise.
• Due to the high risk of evaluating patients over the phone, the patient’s words should always be taken as true.
• If a patient’s call concerns a medical analysis, transfer the call to a licensed professional. Unlicensed professionals may handle nonclinical or non-urgent phone calls.
• If the patient asks for a prescription refill and has visited the office in the past year, the unlicensed professional answering the call may put in the prescription refill order over the phone. If they have not visited the office in the past year, the unlicensed professional answering the call can request that they see their physician before refilling a prescription.
• If the patient calling shows signs of any symptoms or has complaints, recommend an appointment.
• If a patient calls again with unresolved issues from their first call, require an appointment.
• Instruct patients to call 911 in circumstances that include, but are not limited to, allergic reactions, eye injuries, burns, bleeding, loss of consciousness, symptoms of infection, chest pain, or shortness of breath. 
• If you inform the patient to call 911 but they are unable to do so, another staff member should call 911 while you keep the patient on the line.
• Recommend an in-person office visit if the patient seems nervous or apprehensive or displeased with the advice given.
• Ask the caller to clarify any ambiguous and confusing phrases or words.
• Always confirm the caller’s comfort level with and understanding of the determined course of action before ending the call.
• End all calls by giving patients guidelines on when to call back and when to seek emergency care if symptoms worsen.

Lessons Learned

1. Patient safety is the priority and standardized telephone triage protocols used by licensed professionals help provide safe and consistent medical advice over the phone.
2. Unlicensed staff can still answer nonclinical or non-urgent phone calls from patients.
3. All medical staff and patients should be aware that telephone triage and advice calls do not aim to produce official medical diagnoses.

Potential Damages

Giving medical advice over the phone is legally considered medical practice and creates liability exposure because the advice is given without physically assessing the patient. Potential risks include failure to treat and delayed treatment. Using standard protocols, detailed documentation and licensed professionals are great ways to reduce liability.