Page 75 - Avoiding Surgical Mishaps Part 1

SVMIC Avoiding Surgical Mishaps: Dissecting the Risks

After-Hours Calls

Documenting telephone encounters should be treated with
the same level of importance as documenting in-person visits.

Telephone conversations, particularly those that occur after-
hours, are a major area of liability risk. Calls from a patient

outside of normal office hours are often of a serious nature.
Without contemporaneous documentation, the physician has to

rely on memory to recall the advice or recommendation given.

Often, these undocumented conversations become a “he said/
she said” dispute and prolong a claim’s resolution. A simple

note jotted down and then recorded in the medical record
on the front end can save a lot of heartache on the back end.

Contemporaneous documentation of the provider’s instructions
greatly aids in the defense of challenges to the care provided.

A physician may want to use the
SVMIC phone call record pads to

capture information that is received
after-hours and will need to be

documented in the medical record.
These forms can be obtained free

of charge at www.svmic.com. For
paper charts, each slip should be placed securely in the medical

record to prevent loss once the physician returns to the office.

For EHR, the pertinent information from the call should be
entered into section of the EHR with phone note as well as

the appropriate sections of the electronic record (medication/
allergy, problem list, updated treatment plan) as soon as

possible after receiving the call. Otherwise, the clinical decision
support component may be ineffective if changes are not

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