Page 51 - 2020 Risk Reduction Series Effective Systems_Part 1_Flipbook

SVMIC Risk Reduction Series: Effective Systems

those questions. For example, in offices where patients call to

inquire about post-op or post-procedure home care, the use
of patient education tools such as post-op or post-procedure

handouts might be helpful to assist with the development of
effective protocols. Regardless of the source of the protocols,

all protocols should be reviewed and updated by the physician
annually, and documentation should include the words “per

protocol”.

In the absence of written, approved protocols, all of these types
of calls should be discussed with or referred to the physician

for direction prior to advising the patient. This direction should
be documented in the medical record as “per Dr. Smith” by the

office staff individual who responds to the patient after receiving
the direction from the physician. All medications initiated or

refilled should be directly authorized by a physician or advanced
practice provider.

Documenting Phone Calls

The advice given to patients over the telephone often becomes

crucial to his or her continued care and may be vital in the
event of a medical malpractice case.
Therefore, all telephone conversations

with patients, whether they are received

during or after business hours, should be
documented in the patient’s medical
record both for continuity of medical care

and for the defense of a potential

malpractice claim. Documentation should paint a clear picture of
what information was given to the patient. Documentation such
as “spoke with patient” is not as complete and may hinder

continuity of care and defensibility in the event of a claim.

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