business of Medicine
Onboarding Advanced Practice Clinicians
Call coverage guidelines for physicians
Receiving phone calls at all hours of the night covering for several physicians at a time while not being familiar with their patients, not being familiar with the nursing staff, and having to go into the hospital to examine patients, are not only some of the inconveniences of being on call but create liability exposures for all on-call physicians.
Consider the following call coverage guidelines:
- The covering physician should be in your same specialty or competent in your particular area of medicine.
- Backup consultants should be available.
- Hospitalized patients should know about covering physicians, and the length of time they will be covering.
- Verify the covering physician's hospital privileges, the procedures for which he/she has been credentialed and his/her familiarity with hospital routines.
- Use a good “Hand-Off” procedure:
- Review hospitalized patients' current status and any problems with the covering physician.
- Caution the covering physician against prescribing or refilling medication over the telephone. If refills are necessary, request the covering physician prescribe only enough medication to last until your return.
- Provide the covering physician with a list of your office patients who may call and require attention.
- Upon your return, discuss with the covering physician any changes in condition, therapies or special situations, etc.
Other suggestions for decreasing your on-call risks:
- Institute a "Sign-Off" system whereby you can be aware of the status of hospitalized patients or those in the delivery room.
- Ensure that you are able to reach the hospital in a reasonable amount of time.
- Understand the high potential for miscommunication when relying upon phone communications with hospital employees.
- Know the hospital staff and the call system; this is as important as knowing your on-call patients.
- Once you’ve given telephone orders, review them with the nursing staff. Make sure the nurse reads back your orders precisely before hanging up, especially if it is in the middle of the night.
- Review all on-call orders; yours, your partner's, and/or your mid level provider's, when making rounds in the morning.
When you receive a call about a patient with whom you are not familiar, ask multiple questions about the patient, the reason for their hospitalization, their current condition, and any labs before giving an order for that patient. Even aspirin or a stool softener may not always be appropriate. Continue to question the nurse until you are comfortable with your decisions. If there is a potential life threatening condition, or your inner medical voice tells you that the information you are receiving does not make sense, go see the patient. This single effort has saved many an unfortunate outcome. It gives you real time data to make a proper decision. Incidentally, most patients and family recognize the inconvenience and appreciate your efforts to help in the middle of night.
- The on-call physician has a duty to all patients assigned to his/her care during the on-call period.
- Take telephone calls from the nursing staff very seriously; ask extra questions needed to assure you of a patient's stability; take quick notes.
- If there is any doubt in your mind about the information you are receiving by phone, go examine the patient personally.
- Take on-call duty seriously.
A physician, sued for an incident occurring while he was taking call, once stated, “It is better to lose a few hours sleep one night than to lose hundreds of hours over the resolution of a lawsuit caused by not taking care of a potentially avoidable incident while on-call.”
Documentation of patient encounters
The documentation of each patient encounter should include at least the components discussed in this Advisory.
The Chief Complaint
Include a statement as to why the patient came to the office or document a chief complaint. Failure to diagnose and delays in diagnosis are common allegations in medical liability claims. Document the patient’s complains in quotes, when applicable. Include pertinent information such as the onset and duration of the complaint.1
History of Present Illness
Document the description of the patient’s present illness from the first sign or symptom or from the previous encounter. If you ask the patient to complete a questionnaire, acknowledge the document as evidence of your review. Pertinent Findings and Observations of the Physical Examination.
Documentation of the physical examination should include:
- Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s). A notation of “abnormal without elaboration is insufficient.”
- Abnormal or unexpected findings of the examination of any unaffected or asymptomatic body are(s) or organ system(s)
- A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ systems.2 Please note that both positive and negative findings should be documented as appropriate. For example: A patient presents with chest pain; positive findings are pain on inspiration, cough, sputum production; pertinent negative findings are no family history of heart disease, normal cholesterol profile...etc.
- Document vital signs for patients presenting with an acute illness, and before and after an invasive procedure.
Handoffs may be described as the process of transferring primary authority and responsibility for clinical care from one departing caregiver to another incoming one.
Patient handoffs are a necessary component of current medical care, but come with risks. “Handoffs” or transitional errors are among the most common and consequential errors in healthcare. Most patients do not stay in the same place and are not cared for by a single set of doctors and nurses. Handoffs occur naturally as patients move throughout the healthcare system.1
There are various types of handoffs. A patient-related transition may occur because a patient is referred from a primary care provider to a subspecialty physician, or a patient is discharged home from the hospital. A provider-related transition may occur when a patient is stationary, but the providers change due to reasons such as call change.2 When a provider delegates the duty to another provider, the provider who is assuming responsibility for patient care must be aware of the responsibility and have access to all patient information. Covering providers should communicate directly with each other before coverage arrangements begin.
Consider the following recommendations to reduce the risks of handoff communication:
- Implement structured hand-off and sign-out protocols that include an opportunity to ask and respond to questions for the purpose of ensuring continuity of care and safety.
- Structure hand-off communication to include up-to-date information regarding the patient's treatment, condition, and highlighting any recent or anticipated changes.
- Communicate with covering physicians regarding any limitations for prescribing and refilling medications, and issues related to the coordination of care with other providers or specialists.
- Agree about documenting all patient encounters, including before, during and after the hand-off event.
- Schedule a date and time to communicate as soon as possible after coverage ends to discuss patients who experienced serious or unusual problems.
Major transition and handoff issues occur in community practice. The volume of patients seen in the outpatient setting magnifies the problem with handoff communication. We advise that careful consideration be given to the process of handoff communication in order to reduce risks and improve patient safety.
Documenting verbal, e-mail or texting communications in the medical record
The medical record serves many purposes, but its primary purpose is to support and coordinate the medical care of a patient. It is important to think of the medical record first and foremost as clinical communication. Good documentation is critical to support patient care. More specifically, the medical record’s primary purposes are:
- To document the course of a patient’s illness and the treatment that the patient receives or to facilitate the flow of information
- To protect the patient by preserving information that may be needed for future care
- To serve as the main communication tool between all members of the healthcare team
Office procedures should specify documentation requirements for telephone-based, email or texting patient encounters. All communication, either during or after office hours, should be documented in the medical record when one of the following occurs:
- Prescribing or changing medication
- Making a diagnosis
- Directing treatment
- Directing patient to another provider or facility
It is important to include the time and date of the telephone conversation, email or text. The message, along with any advice or instruction given to the patient should be documented in the medical record. Communication with other healthcare providers, such as hospital staff, consultants or testing facilities should also be consistently documented.
The importance of documenting after-hours communications with patients is sometimes overlooked. 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. It is suggested that a system be implemented to ensure prompt documentation of telephone calls and other communications in the medical records. Consider use of secure direct remote entry if available, a reminder notepad or use of voice-messaging.
Obtaining post-discharge records
Patient safety can be compromised by discontinuities in care. Communication among the healthcare team and coordination of care is critical to improving patient outcomes and reducing professional liability claims. Medication reconciliation is an important patient safety initiative to identify changes in prescribed medications, particularly in elderly patients.
For an effective medication reconciliation process to occur in an ambulatory setting, there must be a reliable process to reconcile discharge medications with the current medication list in the outpatient medical record for patients discharged from any inpatient facility and seen within 30 days following discharge. Continuity between inpatient and on-going care is essential.
Numerous studies have documented the prevalence of communication gaps and discontinuities in care for patients after discharge and the significant effect of these lapses on hospital readmissions and other indicators of the quality of transitional care. Current information and communication technology can facilitate the routine completion and transmission of a transition record within 24 hours of discharge, which could greatly reduce communication gaps and may have a positive downstream effect on patient outcomes.1
Underscoring the significance of medication reconciliation, measures are included in the Physician Quality Reporting System (PQRS). PQRS is a reporting program that uses a combination of incentive payments and negative payment adjustments to promote reporting of quality information by eligible professionals (EPs). Beginning in 2015, the program also applies a negative payment adjustment to EPs who do not satisfactorily report data on quality measures for covered professional services.
The measure pertaining to medication reconciliation is # 46; percentage of patients aged 18 years and older discharged from any inpatient facility (eg, hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.2
Providers are encouraged to improve communication and information transfer between the inpatient and outpatient settings and to develop reliable processes for patient follow up. Improved patient education and availability of discharge summaries may prevent medication and care discrepancies that could result in re-admission.
It is important to include the coordination between emergency and primary care physicians in performance improvement efforts.
Relevant National Quality Forum standards include:
- Healthcare organization to develop and implement a standardized communication template for the transitions of care process, including a minimal set of core data elements that are accessible to the patient and his or her designees during care.
- Healthcare providers and health care organizations should implement protocols and policies for a standardized approach to all transitions of care. Policies and procedures related to transitions and the critical aspects should be included in the standardized approach.
- Healthcare providers and health care organizations should have systems in place to clarify, identify, and enhance mutual accountability (complete/confirmed communication loop) of each party involved in a transition of care
- Healthcare organizations should evaluate the effectiveness of transition protocols and policies, as well as evaluate transition outcomes.3
The Institute for Healthcare Improvement (IHI) offers a How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations, June 2013.
The document is available on the IHI website at www.IHI.org.
The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.