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Do you give phone advice to patients? Learn the risks
Do you ever give callers medical advice when they call the ED asking for help? If so, you are facing increased liability risks, warns Peter Alan Bell, DO, FACOEP, FACEP, professor of emergency medicine at Ohio University College of Osteopathic Medicine in Columbus.
"Emergency personnel can be held liable for statements that are made either in person or on the phone that result in a poor medical outcome," he says.
Many EDs have adopted a "no-telephone-advice rule" to reduce risks, Bell says. "You have no existing relationship with the caller, and most callers don’t even identify themselves," he notes.
There is also a risk of misunderstandings, says Bell. "Who said what to the caller? Did both parties understand each other?" he asks. "Often, the medical questions we ask as health care providers make perfect sense to us, yet convey a different understanding to the patient."
When patients call the ED asking for medical advice, do the following to reduce risks:
• Don’t give advice over the phone.
"The rule of thumb is to say, If you think you are having an emergency, hang up and dial 911,’" Bell says. "While we want to be customer-friendly, we do not want to violate the privacy rules, nor do we want to misdirect the patient."
At NorthCrest Medical Center in Springfield, TN, all ED nurses are educated about the risks of giving medical advice over the phone, says Shelley Cohen, RN, CEN, the facility’s ED educator. The ED’s policy is posted at the nursing station and includes the following scripted statement:
"I understand that you are concerned. However, it is not safe nor is it in your best interest to be given medical advice over the phone. You do have three options:
— If you think this is an emergency, hang up now and dial 911.
— If you have a doctor, please call them or whoever is on call for them.
— Go to your closest emergency room."
Having scripted statements by the phone in the ED allows an unlicensed person to route the calls, she says.
• Make sure that nurses know the risks.
Nurses will be less likely to give advice over the phone if they understand the risks of a nurse giving medical advice without signed protocols from a physician, advises Cohen.
"If you can’t give a patient two Tylenol without a doctor’s written, verbal, or standing order, what makes you think it is within the scope of practice for a nurse to give medical advice without the same?" asks Cohen.
• Give patients clear discharge instructions.
To reduce the number of patients calling for medical advice, give preprinted or computer-generated discharge instructions to every patient, says Bell. "These standardized templates avoid confusion regarding what the patient is supposed to do," he says.
• Have a different system for patients previously seen in ED.
If a patient was seen recently in the ED and is calling with questions about a prescription or exacerbation of symptoms, it is appropriate to talk with them, says Bell. Ask the callers for their Social Security number and other identifying information to verify their identity, and document the phone conversation, he advises. "I limit my conversation to answering questions that are pertinent to their current condition, and I often use the discharge instructions as my guide," he says.
If in doubt, ask the patient to return to the ED for a re-evaluation, says Bell. "While I prefer to personally take same-shift calls from my patients, our nurses are trained to follow this same protocol," he adds.
There should be a clearly defined procedure when patients call for medical advice that already have been seen in the ED, says Cohen. She gives the example of a man who was treated for a hand injury in the ED the previous day. He is calling because the orthopedic physician he was referred to will not accept his insurance, and his pain is worse today. The following steps are taken, says Cohen:
— Get the name and phone number of the patient, and let him or her know a nurse will call them back shortly.
— Retrieve the medical record. You will need to verify this is the patient you spoke with. Review the record and content.
— Collaborate with the ED physician on duty. Work together to determine what is best for the patient.
In the above case, options include having the patient return to the ED for a recheck, referring to another orthopedist that will accept the patient’s insurance, or referring to an appropriate clinic, says Cohen.
A licensed person should handle the call, and the ED physician on duty at the time of the call should be consulted, says Cohen. In addition, you should document the following information in the patient’s medical record, she advises: date/time of call, name of caller, questions/advice requested, response given, and name of physician that gave verbal order for the advice.
"Is this more work? Sure it is. But it beats trying to validate that what the patient claims you told them to do were not your words," says Cohen.
For more information about telephone advice in the ED, contact:
• Peter Alan Bell, DO, FACOEP, FACEP, Professor of Emergency Medicine, Ohio University College of Osteopathic Medicine, 1087 Dennison Ave., Columbus, OH 43201. Telephone: (614) 297-4207. Fax: (614) 298-2638. E-mail: firstname.lastname@example.org.
• Shelley Cohen, RN, CEN, Educator, Emergency Department, NorthCrest Medical Center, NorthCrest Drive, Springfield TN 37172. Telephone: (888) 654-3363 or (615) 384-2411. mail: email@example.com.