Page 53 - 2020 Risk Reduction Series Effective Systems_Part 1_Flipbook

SVMIC Risk Reduction Series: Effective Systems

contemporaneous documentation, the physician has to rely

on memory to recall the advice or recommendation given.
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.

The physician utilizing a paper chart 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. Each slip should be placed securely in the
medical record to prevent loss once the physician returns to the

office.

If the office is using EHRs, the pertinent information from the

call should be entered into the 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 entered.

At a minimum, the following types of phone calls need to be

documented in the medical record:

• All phone calls in which test results are reported to

patients, noting if the patient was advised to return or seek
other medical attention.

• All phone calls in which the patient is advised to return or

seek other medical attention, including instructions to go to
the emergency department.

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