Ensure on-call physicians tell you what they've done
Ensure on-call physicians tell you what they’ve done
Communicating the essentials
You are on call for another physician. It is 1 a.m., and the phone rings. On the other end is a patient experiencing worrying symptoms. After giving advice to the patient, you still groggy and in the dark search for a pen and scrap of paper so that in the morning, you will remember the name of the patient you spoke with, the problem presented, and what you did. You hope you will be able to decipher in daylight what you scribbled in the dark and can call the practice you were covering to let them know what transpired.
It doesn’t sound very efficient or very professional, yet that is the way many physicians make it through call duty. But there is a better way, says Edward Cabrera, MD, MBA, FAAFP, medical director of American Medical Healthcare in Orlando, FL.
Cabrera has been providing coverage for physicians for years both short term night call as well as locum services while a practitioner is on vacation or leave. He says that documenting every contact you have with a patient is vital in an age where American’s believe suing a physician is a national right.
"If I get a call from someone who has a sore throat, I may tell them to take some Tylenol," he says. "If they develop meningitis on Sunday and contend I didn’t tell them that they should call back if they get worse or that they should go to the emergency department should they experience certain symptoms, then I better have documentation showing I did."
Along with the potential liability, more insurance companies and managed care organizations are demanding to know what method a practice has for recording actions taken by other physicians, says Neil Baum, MD, a urologist in solo practice in New Orleans.
He believes it is vital for covering physicians to have a predetermined method for recording the events of their call duty and has developed a fax-back form (see copy of form, p. 102) which he requires his covering physicians to use.
By developing a system, both Baum and Cabrera say a practice can impress payers and prevent some of the problems which can lead to litigation. While there are some differences in their approaches to documenting call, they came up with five tips practices can use themselves.
1. Put it on tape.
Physicians don’t take phone interaction with patients seriously enough, says Cabrera, and the midnight scramble for pen and paper is proof of that. For less than $30, he says, you can invest in a small hand-held tape recorder that can be kept in a pocket or on a nightstand. That way, it is always with you, and immediately following a call, you can document what the problem was and what was said.
Once your call is complete, you can either have your own staff transcribe the tapes for the practice for which you covered, send the tape to the practice for its staff to transcribe, or even hire a service that specializes in tape transcription. Regardless, you have the documentation you need in a format which is always legible. "We can’t always read each other’s writing," he adds.
2. Get answering services to provide lists of calls.
Cabrera also recommends that every morning, a list of the calls that came in the night before be faxed to the covering physician. "That way, we can use it as a checklist against the calls we noted on the tape," he says. "If a patient then says they called three times and we never called back, we can see if they are right or not."
3. Give emergency advice.
Always end each call with an admonishment that if symptoms get worse patients should go to the emergency department or call the physician back, Cabrera says. "You’d be surprised how many patients don’t think of that themselves."
4. Make use of faxes and the postal service.
While many practices think that faxes are a godsend and rely on the faxed version of call notes to be inputted into patients’ files, Cabrera believes you should also mail a hard copy to the practice. He prints the transcribed tape notes on sticky-backed paper which can be stuck directly on the file notes. "If the patient calls and says there is a problem, then you don’t have bits of fax paper flying around. You have the notes stuck directly to the file."
5. Ask for clear instructions on exceptional patients.
Baum makes sure that his practice faxes the covering physicians information on special cases or exceptional patients before call begins. He also relies on pharmacists to let him know if there are patients who are known to try to use on-call physicians as a way of getting unnecessary medications.
"Make sure that your ground rules are set out ahead of time," Cabrera says, noting that many of these call relationships are refined over time. "If you have disagreements on major issues, then there is a problem with the relationship. But generally, if you set out the rules in advance, you can avoid most problems."
The whole idea is to improve communications, says Baum. "More medicine is taking place on the phone. That means you have to relinquish your need to actually see a patient. And by documenting what you do, you can ensure that you and your covering physicians have adequate information to effectively treat patients."
• Ed Cabrera, MD, MBA, FAAFP, Medical Director, American Medical Healthcare, Orlando, FL. Telephone: (407) 660-1611.
• Neil Baum, MD, Solo Practitioner, New Orleans. Telephone: (504) 891-8454.
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