Risk Management Guidelines for Telephone Encounters

Executive Summary

More patients are incorporating their phones into their healthcare and are thus calling their providers for clinical advice or questions. Accordingly, healthcare providers need to understand the risks associated with telephone encounters to promote patient safety and compliance with various laws and regulations.

Recommended Actions

• Create a checklist that covers all steps staff members need to take when communicating with patients via telephone. This list may help ensure that all necessary information is obtained from the patient and properly stored. 
• Ensure that all staff members are appropriately trained regarding this checklist or standardized process. 
• If you’re ever in doubt about a patient’s condition, schedule a face-to-face visit, especially if a patient seems overly anxious or unsatisfied with the telephone conversation.

Miscommunication is often at the core of situations that lead to adverse events and possible medical liability claims. One of the key areas where poor communication can impact the quality of care is telephone encounters with patients. These can range from standard administrative interactions to more serious triage scenarios. With the proper guidelines in place, medical professionals can effectively balance meeting the patient’s needs while maintaining the goal of safe and effective care.

Telephone Encounter Procedures

Developing clear and definitive procedures for handling telephone encounters with patients is critical to managing risk. Once procedures are established, all medical and office staff should be properly trained on them and have a solid understanding as to their roles and responsibilities. New office staff should be oriented to the procedures, existing staff should review them, and office managers should consider revisiting how the procedures are used in actual practice to ensure that they are being followed properly.

Procedures should address the following:

• The flow of calls based on level of urgency. Protocols should be in place that define which calls need to be transferred to a physician immediately, which calls can be returned by a physician later (and what a reasonable time frame is for returning calls), and which calls can be handled by other medical professionals at the practice.
• An outline of the scope of advice that can be provided. The information given to a patient must be consistent with the functions that a staff member is trained and licensed to perform. Be sure that each staff member has a clear understanding of what they can say and what they can’t say.
•  A standardized list of questions to ask. Using a standardized list helps to make sure everyone knows what information they need to request and how to record it to maintain consistency in patient records.
• Guidelines for follow-up. Always tell patients when they can expect a return phone call and make sure that internal tracking systems are aligned so patients receive follow-up calls accordingly for specific situations such as providing test results or handling prescription requests.

Documentation Guidelines

All telephone communication, either during or after office hours, should be documented in the medical record or telephone logbook when one of the following occurs:

• Prescribing or changing medication
• Making a diagnosis
• Directing treatment
• Directing a patient to another provider or facility. It is important to include the date and time of the phone conversation.

A telephone message slip with the documented advice and decisions should be securely attached to the medical record. One source of potential provider-patient conflict is that of a phone call made by a patient with the claim that the call was not returned by the provider. A simple log of all incoming phone calls kept in a chronological fashion may help to resolve this source of conflict. Should a patient then indicate that a phone call was made on a particular day, the call can be confirmed by referring to the log. Be aware that if a separate logbook is used to record phone calls, it should be retained securely in the same fashion as a medical record.

Handling Specific Situations

Telephone triage

In these situations, physicians face the challenge of making an assessment based on verbal cues instead of being able to observe patients in-person. If a patient is not able to provide an accurate description of symptoms, guidelines should clearly define when a patient should come into the office or be referred to another provider. Only medical professionals with the appropriate training should provide telephone assessments. If a patient seems overly anxious or unsatisfied with the telephone conversation, a face-to-face encounter should be recommended. The timing of and acuity of that encounter, whether it be in the office, at an urgent care facility or at the emergency department, all depend on the potential severity of the possible underlying diagnosis. And in situations where patients are told to dial 911 immediately, but are unable to, keep the patient on the phone until another staff member can dial 911 on a separate line.

After-hours calls

After-hours calls often deal with what patients perceive to be acute problems and may lead to litigation if they result in poor outcomes or hospitalization. That is why this topic is extremely important for patient safety and risk management.  All after-hours calls must be recorded.

Leaving a message for a patient

Be sure that the patient has agreed to receive potential private health information inquiries via a given modality before leaving a message via that modality. Phone messages left by medical staff should just include a name and a request for a callback. Unless specifically authorized by the patient, you should not leave clinical information or medical advice on an answering machine or voicemail.

Always document that a message was left for a patient in their medical records and have a follow-up system in place to make sure proper contact has been made with a patient. Physicians should never assume that because a message was left, the patient received it.

Telephone encounters continue to be an essential part of patient care, and proper internal procedures and guidelines help to mitigate risk and reinforce patient safety.

Lessons Learned

• Ensure that all telephone communications and any clinical advice administered to patients is immediately documented in the patient’s medical record.
• Before contacting or leaving a message for a patient via telephone, ensure compliance with HIPAA. Ensure that the patient has authorized receiving potential private health information in this manner.
• Ensure that your internal tracking system calendars when patients should receive follow-up calls for specific situations, such as providing test results or handling prescription requests.

Potential Damages

Telephone miscommunications or improper documentation following a telephone call can lead to adverse events and thus costly medical malpractice claims. Additionally, unauthorized telephone communications or communications that inappropriately disclose protected health information could lead to a HIPAA violation and accompanying financial penalties. Although telephone violations can lead to serious financial penalties and/or damages, the frequency of such violations is relatively low.