Page 42 - 2022 Risk Basics - Systems

SVMIC Risk Basics: Systems

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

• All phone calls in which a patient requests medical advice or

prescription refills

Answering Service

If an answering service is used when the office is closed, such service
should be evaluated periodically for courtesy, efficiency, accuracy, and

proper record-keeping. The service should be instructed to immediately
tell the caller that he/she is speaking to an answering service and should

also be given guidelines on what to ask the caller and what action to
take in the event of an emergency. The service will be viewed by patients

as an extension of the physician, and if the patient has a negative or
frustrating experience, it may easily transfer to the physician and serve to

diminish rapport.

Under the Health Insurance Portability and Accountability Act of 1996
(HIPAA), an answering service is considered a business associate since
the service involves the use and/or the disclosure of protected health

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