Patient care can include after-hours telephone calls, which need to be documented by the physician. Many physicians use an answering service that maintains a log of each caller, as well as the reason for calling. Doctors who use an answering service often state that the log is enough to prove that they spoke with the patient. This assumption is incorrect. The answering service's log is a one-way record of incoming calls that does not address the physician's interaction with the patient.
When physicians make after-hours calls, they take on the responsibilities of not just treating the patient but of providing an accurate account of the call as well. Unless the physician uses an electronic medical record that provides access to the patient's data, the conversation takes place without the benefit of a chart to reference details.
After making an after-hours call, the physician should document the interaction and add it to the patient's record. A complete record of an after-hours telephone call should include:
- Identification of both caller and patient
- The date and time of call receipt and return
- The medical reason for the call
- The physician's recommendations given
- Notation of allergy status and current medications if prescriptions are indicated
- Pharmacy phone number
- Physician signature
- Placement of the message into the medical record as soon as possible
CAP's Risk Management & Patient Safety department produces an "After-Hours Patient Telephone Call Record," a fillable notepad that guides the physician with documenting key elements during the phone conversation. The after-hours pads are available to CAP members free of charge. Please fax your request to 213-473-8773.
Authored by
Jackie Gellis-Server, MHA, RN
CAP Risk Management & Patient Safety Department
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.