Reference Library

Telephone Communications

This segment provides a quick, easy-to-use reference guide on one of the most frequent risk management issues encountered in the office practice – telephone communications. It is our intent that this guide focus specific attention on the risk factors of phone communications and suggestions for how to eliminate them.

The telephone poses a growing malpractice risk due to the fact that much of what is said on the phone is never documented. The telephone creates problems with patient relations and perceived quality. The quality of telephone service provided by the office staff has a direct impact on the doctor-patient relationship. For a patient who suffers an adverse outcome, the fact that they were also angered by rude responses to their phone calls, frustrated by the inability to speak with the physician, or not responded to at all, may prompt litigation.

The following are Risk Factors you want to avoid:

Lack of documentation of telephone messages
Inconsistent callback practices
Lack of or inappropriate use of a telephone triage system
System problems with messages getting lost, not given to the correct individual, not followed up, etc.
Inappropriate use of voice mail and automated answering
Lack of documentation of telephone actions/advice

Telephone Triage

When properly implemented, telephone triage systems can improve patient satisfaction and patient utilization by directing them to the appropriate practitioner or level of service. Good telephone triage begins with written protocols for the staff.

Suggested Approaches:

Define the Process

In most instances, trained individuals will utilize a computer or manual system of questions that are specific to the type of symptoms the patient is calling about. The staff member asks a series of questions, and based on the responses, follows an algorithm or flow chat to determine the appropriate recommendations and patient disposition.

Define the qualifications, background and training
for the telephone triage personnel

The policy should include orientation and training processes for personnel. Triage systems that involve actual screening of patient symptoms should utilize registered nurses with substantial clinical experience.

Identify specifically what the telephone triage will cover

Define the hours of operation

Identify whether the system will cover after-hours calls or screening and referral during regular business hours.

Define where and how callers will be referred

Care protocols should clearly define what symptoms indicate which level of referral option.

Answer the following questions:

Will the patient be seen immediately?
Will the doctor call the patient back?
Should the patient be directed to an ambulatory care center?

There must be clear identification of emergency situations

The staff must be clear under what circumstances the physician is to be interrupted. It must also be clear under what circumstances the patient needs to seek emergency care. The telephone numbers of all local emergency services and poison control centers should be posted in an accessible location.

Define the process for patient appeal

There must be a system that allows for the patient to dispute the advice of the telephone triage personnel and go immediately to the next highest level in the system. In many instances, when a patient requests to speak with a physician specifically following speaking with telephone triage personnel, that request is honored.

Documentation is essential

The policy must define how each call will be documented.

There must be a system for continuous review and improvement

The policy should define a system for reviewing clinical accuracy and customer satisfaction on a regular basis.

There are computer systems available for telephone triage which have published protocols

The American Academy of Pediatrics 847-434-7662 and the American Academy of Family Physicians 800-944-0000 have published triage protocols.

Limitations of protocols include the following:

Protocols must be coupled with good clinical judgment
They help define symptoms – they do not provide medical diagnosis
They cannot replace a physician’s independent professional judgment. It is important to note that telephone triage protocols do not provide medical diagnosis or treatment advice, but give general health information.

Do not ignore or minimize the “routine” complaint

Always end the call by advising the patient to call back if their symptoms worsen. Always advise the patient on how to obtain emergency treatment.

The staff must identify themselves by name, and indicate their licensure or certification and the intended scope of the telephone triage system

Do not put a patient on hold unless you have determined that they do not have an emergency

Document all communications with the patient, including prescription refills, advice or instructions given, etc. Confirm the patient’s understanding by having them repeat the instructions back to you.

How the patient views the doctor depends a great deal on how personnel answer the telephone and handle patient calls. When a patient calls the medical practice, routing the call to the appropriate person expedites the information gathering process. The telephone is commonly the area of office policy over which the physician has the least control. As physicians and staff exchange information over the telephone, proper protocols and documentation of such communication is vital. A physician can be held responsible for incorrect, inappropriate or incomplete information.

The office telephone is the link between the physician and the patient. Telephones that are not answered promptly, prolonged busy signals, lost messages, and curt receptionists are not only bad practice, but can also lead to a lawsuit.

Telephone etiquette policies and procedures should include:

Office standard procedures should be covered with all new patients.
Confidentiality maintained at all times.
Notice of where phones are located in the office and awareness of who may be in earshot.
Identify the office practice and the identity of the personnel taking the call.
Ask permission before you put a caller on hold.
Don’t leave callers on hold longer than 30 seconds.
Follow-up phone calls or advice should not be given without having the patient’s chart in hand.
All messages should be permanently affixed to the patient’s medical chart.
Medical information should be given only by the physician or by designated medical personnel under guidelines.
All calls should be returned by the end of the day – patients should be advised when they can expect a return call.
Physicians should accept calls when requested to do so by office staff.
Options should be simplified for automatic call distribution. Emergency information should be given early in the message.
Answering service/machine should be checked every day at designated times.
Answering service/machine messages should be documented in the patient’s medical chart.
Practice should make periodic assessment of their phone lines to determine if they are adequate for the size of the practice.
Cellular phones are not confidential lines.
All messages should be written on telephone message slips and should include the following information.

Date of the message

Time

Patient’s name

Name of caller

Relationship to the patient

Urgency

Reason for call

Allergies

Handled by

Call back time

Call back number

Physician orders

Follow-up, including – action taken, advice given and action planned

Periodically review staff training, telephone procedures, and protocols to ensure that inquiries are being appropriately managed. Failure to document phone calls relating to medical information leaves gaps in the patient’s record that may be difficult to defend in allegations of failure to follow up or patient abandonment. The few minutes taken to record this information will be valuable for ongoing patient care. Without it, the potential for patient dissatisfaction, missed diagnoses, delay in treatment, and possible serious medical consequences exists.