Documenting telephone calls at your dental practice is just as important as documenting patient visits.
Similar to other documentation, the common rule when it comes to call documentation is that if it is not documented, it did not happen. Therefore, every clinically relevant telephone call should be documented.
Clinically relevant calls include those pertaining to symptoms, medications, disease process and management, test results and/or patient education.
It is recommended that you establish call documentation protocols for your practice. Set protocols allow for clear and timely documentation that can help in avoiding disagreements over what was said, when it was said and why it was said.
To establish call documentation protocols at your practice, consider the following tips:
1. Be proactive regarding call documentation by developing a policy and corresponding procedures.
• Train staff members in telephone protocols and authorize them to interrupt the provider as necessary
• Provide non-clinical personnel with guidelines to appropriately respond to emergency/urgent care concerns
2. Be specific.
• Record the content of the call in the patient’s record
• Include any advice/instructions provided and the patient’s understanding of that information
• Include the name of the staff person who took the call-in addition to patient requests, concerns and issues
• Document all follow up conversations and calls concerning previously discussed problems, recommendations and test results in a timely manner
• Document calls and conversations with family members (who called and their relationship to the patient) and relay this information to the provider or designated staff member
• Rather than having a patient call the provider back, have the provider or designated staff member return the call
o Advise the patient of approximately when they may receive a call back, from whom and confirm the number where they will be at that time
3. Periodically review the telephone responses and documentation to bring to light when additional staff training, or a policy revision may be required.
You should never feel that call documentation clutters your records. Instead, consider call documentation as an essential opportunity for documenting your communications with patients, leading to a complete and accurate medical record.