What Should I Document After a Patient Telephone Consultation?

Elayne DeSimone, PhD, NP-C

Disclosures

November 09, 2000

Question

What are the medical-legal issues related to telephone consultations and documentation? For example: A child is seen in the office and diagnosed with acute otitis media and placed on antibiotics. However, in 3 days, the child has not improved and the parent telephones the office for further advice. At that point the treatment is changed and I contact the pharmacy. Should I document the conversation with the parent and the change in treatment in the patient chart? What are the legal ramifications if this is not done?

Donna Driscoll, MSN, CPNP

Response from Elayne DeSimone, PhD, NP-C

Telephone management of episodic illness is a common practice in both pediatric and adult care. Although this question raises the issue of the importance of documentation, there are several related issues that come to mind. These include the quality of the telephone interaction, recommendations for care or referral, and the potential for reimbursement for services that are provided by means of the telephone.

The above scenario describes a situation in which the nurse practitioner has performed an initial evaluation of the patient. There are, however, potential situations in which telephone triage may be required as an initial patient encounter and not as follow-up. Use of a predetermined telephone protocol should help to ensure quality care and documentation. Once the protocol is established, several methods of documentation may be instituted, as is discussed below.

It becomes important to document the encounter for medical-legal reasons, adequate follow-up care, and the process of continuous quality improvement.[1] The NP may choose to record the encounter directly on the patient's chart or institute the use of telephone logbook.

Response from Elayne DeSimone, PhD, NP-C

Date__/__/__ Time_______am/pm Caller______________________

Patient _____________________ phone#_________________

Reason for call_______________________Diagnosis:___________________________________________________

Present Meds__________________________Allergies________________________

Recommendations/Rxs____________________________________________________________________

Pharmacy___________________phone#___________________________________

(Brief- 99371)

(Intermediate - 99372)

(Complex - 99373)

The date and time should be recorded along with the elapsed time of the encounter. Brief patient data, including relevant ICD-9 codes, are helpful in follow-up care or to identify trends during quality improvement assessments. All recommendations for care, including calls to other health care providers, and patient instructions should be included. Some insurance companies recognize telephone management as a reimbursable service.[2] If this is the case, it then becomes important to determine the level of care provided in addition to the above-mentioned information (ie, brief, intermediate, or complex encounter).

While telephone discussions preclude the advantage of face-to-face interactions, the NP must be particularly attuned to the caller's emotional state and ability to follow verbal instructions.[3] Always ask the caller to repeat the instructions given. Encourage the patient to record any specific instructions that are given over the phone.

Comprehensive documentation is recommended as a risk management strategy. Recording the encounter directly onto the patient's chart (or attaching a copy of the log entry) will improve the quality of any future office visits. Comprehensive documentation will lessen the NP's liability and improve communication and, therefore, patient care.

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