How Should I Document an On-Call Patient Consultation?

Carolyn Buppert, MSN, JD

Disclosures

March 12, 2018

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Question

A nurse practitioner (NP) wrote in with a question about being on call: "When I am on call, I may be away from my computer, without access to the patient's electronic medical record. What are my responsibilities with respect to documenting what I have prescribed or advised?"

Response from Carolyn Buppert, MSN, JD
Healthcare attorney

You'll need to document, as soon as possible, what the patient told you, what you told the patient, any prescriptions you called in, and the plan for follow-up. You can do that in the electronic health record, or you can fax or email a note to the office. Your organization should have a policy on how the organization processes on-call documentation.

The rationale for careful documentation of patient interactions is twofold. First, if something goes wrong and there is a bad outcome (and a lawsuit), you will need your documentation to support your decision-making. And providers who see the patient in the future will need to know what you did and what you told the patient.

Note that documentation of what you told a patient won't be helpful if any audio recording of the call contradicts what your records say. Here is one case where an on-call provider was sued, and her documentation was not helpful[1]:

A 9-year-old boy who was thought to be previously healthy developed nausea and vomiting, poor appetite, lethargy, and weakness for 3 days. The boy's father called the pediatrician's office on a Saturday night. An NP was on call. When the NP returned the call, the father said that the boy had slept for 24 hours straight but had been carried downstairs to watch TV and was sipping ginger ale. He had had some rectal bleeding and some bleeding from his mouth during the day.

The NP told the boy's father it sounded like a viral illness, but that the rectal bleeding could be something different. She asked:

  • Was he alert? The father said yes, but very tired.

  • Had he passed any urine? The father said yes.

  • Did he have a fever or rash? The father said no.

Then the NP asked the father whether he thought the child needed to be seen right away. The father said he thought it could wait until morning. The NP made plans to see the father and his son after 8 AM. She instructed him to call back if anything developed during the night. The NP told the father to push the ginger ale and make sure the boy was urinating.

There was an audio recording of the call. The NP documented her advice in the medical record, including the fact that the father was offered an emergency department visit. However, the audio recording did not verify a specific offer of an emergency department visit.

When the father checked on the boy at 4 AM, the boy was sleeping and the father noted that his breathing rate had increased. Later in the morning, the boy was not breathing. The father called 911 and started cardiopulmonary resuscitation. When an ambulance arrived, the child was apneic and pulseless, with fixed and dilated pupils, and his corneas were cloudy. At 9:30 AM, the child was pronounced dead.

An autopsy found the cause of death to be diabetic ketoacidosis. There was no previous diagnosis of diabetes. The boy's blood sugar level was 1165 mg/dL (normal, 50-80 mg/dL); potassium level was 7.1 mEq (normal, 3.5-5.3 mEq); and his A1c was 15.3% (normal is 4%-5.9%).

The parents sued the NP, alleging wrongful death of their son due to negligent delay in diagnosis and treatment of diabetic ketoacidosis. The case was settled for an unknown amount of money.

The insurer in this case had this general advice about telephone triage: A clinician or practice may decide not to provide advice over the telephone, especially to an unknown patient. However, if giving telephone advice, there should be protocols in place as to the questions the provider should ask and when a patient should be referred, and there should be a mechanism to record what was discussed and what advice was provided.

One additional note of caution: Any time a clinician takes patient records with him or her, on a laptop, there is a risk that the laptop will be lost or stolen, and then the clinician is liable for a violation of the Health Insurance Portability and Accountability Act. So, a clinician needs to balance the risk of waiting until later to document against the risk associated with keeping records with him or her at all times.

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