The failure to properly handle and document after-hours telephone calls can adversely affect patient care and lead to potential liability exposure for the healthcare provider. Patient communication that is not documented may increase a healthcare providers liability exposure.
It is recommended that:
1. A system should be established in order to ensure that all after-hours calls are responded to in a reasonable time frame and are documented in the patient’s medical record.
2. Medical record documentation of after-hours calls should include the following:
• Patient’s name;
• Name of the caller, if different than the patient, and the individual’s relationship to the patient;
• Date and time of the call;
• Reason or nature of the call, including a description of the patient’s symptoms or complaint; and
• Medical advice or information that was provided, including any medications that were prescribed.
3. If the patient’s condition necessitates the need for a prescription, it is important to inquire about and document any medication allergies, as well any other medications the patient is currently taking.
4. If a healthcare provider utilizes an answering service, the service should be periodically evaluated for courtesy, efficiency, accuracy, and proper recordkeeping.
5. The use of answering machines or voicemail systems for after-hours calls is not generally recommended.
6. When after-hours coverage is provided by another healthcare provider’s practice, a process should be in place to ensure that documented telephone conversations are promptly forwarded to your office.
Every healthcare provider should have a policy and procedures in place in order to manage and document all after-hours telephone calls from patients.
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