Page 40 - 2022 Risk Basics - Systems

SVMIC Risk Basics: Systems

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 of their use by the staff 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.

An example of the importance of recording any advice given after-hours

is seen in a synopsis of a closed case.

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