Dilemma: Patients call about discharge orders

Clarify instructions, but don't diagnose

You probably know the legal risks of giving medical advice over the telephone, but did you know that different rules apply when patients are calling about their discharge instructions?

"The only acceptable telephone advice in the ED is clarification of advice on discharge instructions," explains Stephen A. Frew, JD, vice president and risk consultant with Johnson Insurance Services, a Madison, WI-based company specializing in risk management for health care professionals.

However, the call should be documented on the record, and there should be a "verbal order" documented from the doctor as to what the patient was told, says Shelley Cohen, RN, CEN, an educator for Health Resources Unlimited, a Hohenwald, TN-based consulting company specializing in ED triage and health care leadership. For example, you should document the date and time of the call on the patient's chart. Also, you should document, for example, "Patient called two days later because he forgot to mention he was recently placed on a new heart pill. He wants to know if it is safe to take this pill along with the prescription he was given."

If a patient calls with this kind of question, you should do one of the following, says Cohen:

  • Put the patient on hold, ask the physician what he or she recommends, document this as a verbal order and relay it to the patient, and have the physician sign your note.
  • Take the patient's name and phone number, and call him or her back after you have discussed the concerns with the ED physician. "The doctor on duty may want a chance to review the record before making a recommendation. Then document what the recommendation is," explains Cohen.

If the patients are calling back because they don't understand your instructions, you need to decide whether the patients are best served by returning for re-education or by being given instructions over the phone. "Common sense, critical thinking, and nursing judgment should prevail here," says Cohen.

Patients may say they cannot read the instructions, cannot find them, or don't know what a word means, says Frew. Since these questions do not involve giving medical advice outside the scope of the discharge instructions, this type of information has a low potential risk of harm to the patient or liability risk to the nurse, he explains.

"I would have little concern with responding to these questions during the first 24 to 48 hours," he says. "After that, the question should probably be directed to the physician's office."

If patients ask a question such as, "How am I supposed to change my dressing?" this falls in the area of patient education and is appropriate to the nursing scope of practice, says Frew. If the caller does not seem to understand your verbal clarification, refer them to their physician's office, their insurance company ask-a-nurse service, or suggest they come back to the ED, he adds.

However, if the patient asks whether their condition is bad enough to come back to the ED, this is a different story, says Frew. "The caller has crossed into the danger zone by asking for a medical diagnosis over the phone," he says.

While some callers overreact to minor situations, most are probably looking for reassurance that they don't need to come back to the ED, says Frew. "When the situation later proves to have warranted an ED visit, the caller feels guilty and tends to place the blame on the nurse who gave them 'permission' not to come in," he says. In this case, suggest that the patient come back to the ED or call 911, says Frew.

Cohen says other than clarification of discharge instructions, the only advice you should give over the phone is to say, "If you think you need to be seen by a physician, you can go to an emergency department, an urgent care center, or your primary care physician's office."

Likewise, nurses should avoid talking about the cost of the ED visit, she says. "Simply state that all persons are entitled to emergency care regardless of their ability to pay," says Cohen. "This advice is applicable to both patients and family members [asking for advice]."

An automated discharge instruction system should reduce the number of these calls, except if the patient has thrown the instructions away or lost them, adds Frew.

Instructions should be sufficiently detailed, written in simple language, and available in foreign languages used by the patient populations served in your ED, adds Frew. "A signed copy of the discharge instructions should be placed in the medical record to ensure that there is no question that the patient received instructions and what they contained," he says.

Sources

For more information on discharge instructions in the ED, contact:

  • Shelley Cohen, RN, CEN, Health Resources Unlimited, 522 Seiber Ridge Road, Hohenwald, TN 38462. Telephone: (888) 654-3363 or (931) 722-7206. Fax: (931) 722-7495. E-mail: educate@hru.net. Web: www.hru.net.
  • Stephen A. Frew, JD, Vice President-Risk Consultant, Johnson Insurance Services, 525 Junction Road, Suite 2000, Madison, WI 53717. Telephone: (608) 245-6560. Fax: (608) 245-6585. E-mail: sfrew@johnsonins.com.