Risk Management

Documenting Patient Calls Is Prudent Risk Management

By Michael R. Redmond, MD

Argus, July, 1992

Most ophthalmologists know that the telephone is essential to their practice, but few think of it as an important aspect of risk management. Because the telephone is usually the patient’s first contact with the ophthalmologist’s office, it should be used to make the patient feel welcome and important, not put off or ignored. Telephone contact alone may be considered enough to establish the physician-patient relationship. Accordingly, telephone contact should always be courteous and helpful so patients hang up feeling that their problems will receive the proper attention and will be resolved appropriately.

The ophthalmic office staff often are responsible for “telephone triage.” Inability to reach the ophthalmologist by telephone in times of perceived crisis is a common complaint of patients. Untrained staff without proper guidelines for handling urgent and emergent care can create the risk that patients may not receive care in a timely manner, or that incorrect or inappropriate advice will be given out.

Every office should establish prescription renewal procedures. The staff person handling the renewal should secure the ophthalmologist’s verbal approval, document it fully in the chart, and date and sign it. Although not all telephone contacts require documentation, anything unusual-an angry, belligerent or threatening patient, for example-should always be well documented.

The ophthalmologist and office staff must be careful about giving treatment, advice or explanations, or obtaining informed consent over the telephone. Always have the chart available before talking to a patient, and document these conversations. They can be quickly recorded when the chart is in hand at the time of the call.

Treating a patient over the telephone without examination may leave you open to criticism. There is always the risk of incomplete information, misinformation or drug misuse, especially in a multi-physician practice where all the particulars of a patient’s condition may not be known to the ophthalmologist taking the call. Always ask about potential “problem patients” before assuming a call for another physician and pass on this information to any ophthalmologist covering for you, both as a courtesy and in the interest of patient care.

Periodically review your after-hours answering service as to qualifications, courtesy and timeliness of physician contact. Physicians have been held vicariously liable for the failure of their answering services to contact them in a patient emergency.

Once again, documentation is critical. Each physician in a practice should have a logging system both at the office and at home for recording and transcribing telephone notes into the office chart in a timely fashion. Nothing is more comforting when you are challenged than being able to go back to the chart and pull up an old note supporting your position.

Pre-printed phone record pads ensure that office staff renewing prescriptions by phone document the necessary information. This should include the approval of the treating physician, the caller’s and patient’s names, a phone number where they can be reached, a brief history of the patient and the nature of the call, the prescription name and recommended follow-up, and the pharmacy filling the prescription. The staff person should date and initial the phone call record, and indicate the times the call was received and returned.

OMIC offers pre-printed telephone record pads to its insureds. Call OMIC at 415-202-4652 for more information.

This continuing series on risk management is presented by the Ophthalmic Mutual Insurance Company (OMIC), a risk retention group providing professional liability insurance exclusively to Academy members. If you have comments or questions, write or call OMIC, 655 Beach St., San Francisco, CA, 94109 or (800) 562-6642.