MLMIC Risk Management Tip #8 addresses medical professional liability risks related to “Management and Documentation of After-hours Telephone Calls from Patients.”
The failure to properly handle and document after-hours telephone calls can adversely affect patient care and lead to potential liability exposure for the physician. Should an undocumented telephone conversation become an issue in a lawsuit, the jury is less likely to believe the recollection of the physician, who receives a large number of calls on a daily basis.
- Establish a system to help ensure that all after-hours calls are responded to in a reasonable time frame and are documented in the patient’s medical record.
- 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
- Medical advice or information that was provided, including any medications that were prescribed
- If the patient’s condition warrants the prescription of medications, it is important to inquire about and document any medication allergies, as well any other medications the patient is currently taking.
- If you use an answering service, it should be periodically evaluated for courtesy, efficiency, accuracy, and proper recordkeeping.
- The use of answering machines or voicemail systems for after-hours calls is not recommended for the following reasons:
- There are no safeguards in the event of a malfunction.
- Patients do not always understand that no one will call back, even if this is stated in the message.
- If, as a last resort, an answering machine or voicemail must be used, the message should be brief, simple, and include: (The office is now closed. If you believe you are experiencing a medical emergency, please disconnect and call 911.)
- When after-hours coverage is provided by another physician’s practice, a process should be in place to ensure that documented telephone conversations are promptly forwarded to your office.
This MLMIC Risk Management Tip is available here as a PDF: “Management and Documentation of After-hours Telephone Calls from Patients.”