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Get the Message? |
When physicians think of documentation, they often overlook the lowly phone message pad. In many cases, however, written phone messages are the “missing link” of clinically relevant physician/patient communication that can affect a patient’s medical outcome. Phone messages, therefore, should be taken very seriously – sometimes the most crucial piece of evidence is the smallest.
Phone messages can be documented directly in the chart, but if you’re too busy, consider using a message pad, especially a carbon copy pad. That way one copy can be filed in a timely fashion in the patient medical record, while the other can be given to support staff for immediate action (e.g., a nurse can phone the pharmacy or confer with the physician for treatment recommendations.)
Physicians and medical staff should document:
• All clinically relevant phone calls
• All calls involving prescription medication (questions, refills, etc.)
• All calls that involve communication of test results (X-rays, lab reports, etc.)
• All calls from patients involving complaints or complications
• All follow-up calls (test results, post-procedure check-ups, billing issues, etc.)
Don’t forget – phone messages, like other written documents, will not help a physician facing allegations of medical malpractice if not filed in the patient’s medical file in a timely fashion. In fact,filing a phone message after files have been subpoenaed is more damaging than not having any record at all – it’s considered an alteration of the patient’s medical record. Get the Message?
Pad the Message with ISMIE!
Are phone messages the “weakest link” in your patients’ medical records? If so, ISMIE Mutual can help. For a limited time, ISMIE’s Risk Management division will be offering sample phone message pads to ISMIE policyholders, free of charge. These carbon-copy pads will “prompt” the message taker to ask for information that will facilitate the creation of a clinical relevant document in the patient’s medical record.
To order, please call ISMIE’s Risk Management division at (800) 782-4767, ext. 1627.