Telephone Triage and Medical Advice

By Susan Shepard, MSN, RN, Director, Patient Safety Education.

Miscommunication is one of the most common causes of adverse patient events in the physician’s office setting. Telephone communication, a critical part of the patient’s overall care and management, presents a significant area of liability exposure.

Implementing an effective telephone triage system in the office practice can improve physician-patient communication, confidence, service, satisfaction, and care. It can also reduce emergency medicine department (EMD) visits while ensuring that the patient has access to the appropriate level of care. However, telephone triage, a form of telemedicine, has its own risks.

Telephone triage guidelines require accurate assessment without the benefit of a face-to-face encounter. For this reason, only licensed professional staff with appropriate training should provide telephone assessments. Required qualifications and training should be clearly defined in the job descriptions of personnel who perform telephone triage. Staff members who take initial calls should have written protocols that include specific examples of questions to ask the caller, recommended responses for minor problems, and an outline of the types of calls to refer immediately to a physician or schedule for an office appointment.

It is important that patients and family members/callers understand the limitations of telephone advice. Inform patients in writing about situations that are appropriate for telephone advice (such as minor headaches, cuts, and bruises). Providing patients with examples of the types of problems likely to require an office or EMD visit will aid them in accessing the most appropriate care. Recommend a face-to-face encounter when a patient or a family member/caller seems overly anxious or dissatisfied with the advice given or if the patient believes the situation is urgent.

Instruct patients to dial 911 in situations that involve (but are not limited to) allergic reactions, chest pain, eye injuries, burns, or shortness of breath/wheezing. Office staff should have identified situations in which the patient should be told to hang up and dial 911. Certainly, if the patient is unable to dial 911, he or she should be kept on the line while another staff member calls 911.

Triage algorithms can assist registered nurses or mid-level practitioners in documenting telephone conversations. The physician should review all telephone triage decisions. If a patient needs to be seen in the EMD, the physician should phone the EMD with a presumptive diagnosis or a description of symptoms.

Document Telephone Interactions

All information related to medical advice given over the telephone should be documented thoroughly and a follow-up call should be made to the patient. In a claim resulting from telephone triage, an undocumented interaction can lead to a case where it is the patient’s word against the staff member’s or physician’s word.

A call asking for advice may seem insignificant at the time, but an adverse event can occur if the patient fails to follow the recommendation. Documentation is vital in defending a claim or suit. Regardless of when or where the contact occurs, telephone interactions should be recorded in the patient’s medical record.

Advice Protocols

Advice protocols have been used in physician practices to ensure consistency in the information collected, recommendations made, and documentation of telephone interactions between patients and physicians or nurses. Some protocols provide triage guidelines for licensed staff responding to callers who have specific problems and associated symptoms.

Advice parameters help registered nurses and mid-level practitioners decide where and when patients should access treatment. Protocols can also provide guidance as to when further telephone assessment may be inappropriate. For example, one set of protocols addresses common concerns in newborns, such as cradle cap, circumcision care, and umbilical cord problems. The protocol can include the warning, “Exercise extreme caution when assessing infants [and that] any suspicion of illness indicates an evaluation is appropriate.”

Telephone advice protocols are not intended to lead to medical diagnoses. This limitation should be made clear to all staff and to any patients who call. Published telephone advice protocols are available from various sources. If used, the protocols should be reviewed and adapted by physicians to meet the specific needs of the practice and to ensure that the protocol is in accordance with the standards of care. It is important to ensure that nurses or other licensed professionals giving telephone advice conform to the state’s practice acts and have specific training, experience, and competence in telephone assessment techniques.

Failure to follow scope-of-practice requirements by non-clinical personnel is a common malpractice liability issue in physician offices. To minimize your liability, implement appropriate job descriptions for all categories of office staff, and never allow staff to act outside their scope of practice.

Patient Safety Recommendations

  • Develop policies and protocols for office and nursing staff to follow. Staff should respond to all calls in an appropriate manner.
  • Train staff regarding questions to ask the caller and when to refer a call to the physician immediately. The physician will then know that if he/she is summoned to take a call, the patient has an urgent or emergent need.
  • Document all calls in which medical information or advice is provided. Documentation should include the date, time, patient’s name, name of caller/relationship to patient, complaint/concern/question, and advice given.
  • Make sure that office staff checks with the doctor first if there is any doubt about proper instructions or advice. Instruct staff to never practice medicine over the phone or to give advice beyond their competence.
  • Educate physicians about the importance of being receptive to questions by office staff.
  • Instruct staff to obtain as much information as possible about the problem.
  • Document critical negative information that helped determine the advice that was provided. Examples: “mother stated the child has no fever, no lethargy, or neck stiffness” and “mother stated the child has a good appetite and is taking fluids.”
  • Establish a reasonable time frame in which non-urgent calls are expected to be returned. If possible, build time into the physician’s schedule to return calls.
  • Inform patients when they can expect a return call.
  • Review telephone procedures and protocols with staff periodically to ensure that inquiries are being appropriately managed.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

J9531 12/13

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