Telephone Triage and Medical Advice Protocols

Debra Kane Hill, MBA, RN, Senior Patient Safety Risk Manager, and Richard F. Cahill, JD, Vice President and Associate General Counsel, The Doctors Company

Analysis of our closed claims data shows that miscommunication is one of the most common causes of adverse patient events in the office setting. We found that communication involving telephone triage and advice—a critical part of the patient’s overall care and management—presents a significant area of liability exposure.

Telephone Triage

Telephone triage is the process of managing a patient’s call to the office to determine the urgency of the medical issue, the level of staff or provider response required, the appropriate location if the patient needs to be seen, and the timing of appointment scheduling.

Implementing an effective telephone triage system in the office practice can improve provider-patient communications, quality of service, patient satisfaction, and continuity of care. It can also promote optimum clinical results and reduce emergency department (ED) visits while ensuring that the patient receives timely access to the appropriate level of care.¹

Note that the telephone triage process is separate and distinct from the guidelines that practices should develop and implement for visits designated specifically as telehealth encounters. For more information on this topic, see our article “Top Seven Tips for Telehealth.”

Addressing Triage Risks

Telephone triage involves inherent risks, however, because it requires an accurate assessment of the patient’s concerns without the benefit of a face-to-face visit. For this reason, allow only licensed professional staff with appropriate training to triage patients by telephone.

Clearly define the necessary qualifications and training in the job descriptions for licensed personnel who perform telephone triage. Provide written protocols for unlicensed staff members who take initial calls. Include specific examples of questions to ask the caller and recommended responses for minor problems. Outline the types of calls that require an office visit, a transfer to the licensed provider for a more detailed evaluation, or an instruction to call 911 for immediate emergency response. Office staff must have clear guidance and repeated simulation training on situations that require calling 911 for immediate emergency support.

Explain to your patients that not all issues can be treated over the phone and the practice determines whether a patient should be seen in person. When a patient or other caller seems overly anxious or dissatisfied with the telephone advice provided or if the patient believes the situation is urgent and requires more immediate and in-depth attention, arrange for a face-to-face encounter.

For emergency calls, instruct patients to dial 911 in situations such as (but not limited to) allergic reactions, abdominal or chest pain, eye injuries or visual disturbances, head injuries, burns, active bleeding, loss of consciousness, convulsions, signs or symptoms of infection, fever lasting more than 48 hours, early onset of labor, casts that are too tight, stroke symptoms, or shortness of breath and/or wheezing. Additionally, if the patient is unable to dial 911, a staff member should keep the patient on the telephone while another staff member calls 911. This will ensure a smooth and seamless transition to the next level of emergency service.

Triage Resources

Medical offices have various options for establishing triage services and medical advice protocols within their practices and medical specialty. Sources available in the marketplace for triage protocols and implementation of services include artificial intelligence using triage algorithms, EHR systems, professional societies, medical associations, commercial products, and contracted services.

• Triage algorithms can assist licensed clinical staff in responding to patients and documenting telephone conversations. The responsible provider should review all telephone triage decisions prior to utilization in the practice. If a patient needs to be seen in the ED, the provider should contact the ED with a presumptive diagnosis, a description of symptoms, and the information obtained by the practice during the telephone encounter.

• Clinical decision support systems (CDSS), a type of digitalized tool, aid in clinical decision making. According to the Office of the National Coordinator for Health Information Technology:²
• Clinical decision support (CDS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support; and contextually relevant reference information, among other tools.
• Keep in mind that when using a CDSS, the provider’s assessment may not be exactly congruent with the CDSS prompts. In this circumstance, providers should document their rationale for clinical decisions.
• Telephone advice protocols are used in ambulatory practices to ensure consistency in the information collected, recommendations made, and documentation of telephone interactions between patients and clinicians. Advice protocols help clinical staff decide where and when patients should access treatment. Protocols can also provide warnings about when further telephone advice 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 might include the warning, “Exercise extreme caution when assessing infants. Any suspicion of illness indicates that an in-person 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. If using published protocols, providers should review and adapt the protocols to meet the specific needs of the practice and ensure that the protocols are in accordance with the standards of care and recognized authoritative sources. It is important to ensure that licensed clinical staff who give telephone advice conform to the state’s practice acts and have specific training, experience, and competence in telephone assessment techniques.
• Unlicensed personnel should never be allowed to triage by telephone or provide telephone advice. According to Don Basala, JD, MBA, CEO and House Legal Counsel for the American Association of Medical Assistants (AAMA), “I define triage as a communication process with a patient (or patient representative) during which a health care professional is required to exercise independent clinical judgment and/or to make clinical assessments or evaluations. It is my legal opinion that it is not permissible for medical assistants to be delegated triage (as I define the term).”³
• Failure to follow scope-of-practice requirements by nonclinical personnel is a common malpractice liability issue in provider offices. To minimize your liability, implement appropriate job descriptions for all categories of office staff, train your staff, document their training, and do not allow staff members to act outside their scope of practice.

• Contracted triage services in the marketplace are also an option for medical practices. Use reputable services that hire only licensed healthcare personnel and follow protocols that follow the standard of care for the medical specialty. Providers should review call protocols periodically as the practice provider is responsible for the instructions given to their patients by the service.

Document Telephone Advice

Thoroughly document all information related to medical advice given over the telephone and make a follow-up call to the patient. In a claim resulting from telephone triage or advice, an undocumented interaction can lead to a situation involving the patient’s word against the staff member’s or provider’s word. Plaintiff’s counsel will be quick to point out the old adage, “If it’s not recorded, it never happened.”

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. Documenting patient instructions is vital in defending any claim that might be filed later. Use the Teach-Back Method (“repeat-back”) to confirm that the patient received the message accurately and document the patient’s understanding. Regardless of when or where the contact occurs, record all telephone interactions in the patient’s medical record promptly. Do not neglect to include after-hours phone calls, too. It is important to implement a system to ensure that all clinical calls received after hours are captured in the medical record.

Patient Safety Strategies

The provider is ultimately responsible for telephone triage and any medical advice given to the patient. Implement the following strategies to minimize risks:

• Implement written policies and protocols for office and clinical staff to follow when triaging calls and providing advice. Conduct periodic chart audits to ensure that policies and protocols are followed. Review the guidelines annually and revise as circumstances warrant.
• Train staff regarding questions to ask the caller and when to refer a call to the provider immediately. The provider will then know that if he or she is summoned to take a call, the patient has an urgent or emergent need.
• Instruct staff members to follow the advice protocols and check with the provider first if there is any doubt about proper instructions or advice. Failure to do so may be considered the practice of medicine and practicing beyond the staff member’s scope of practice.
• Require staff members to refer calls directly to the provider if a patient calls a second time with a complaint that was not resolved by previous telephone advice.
• Require an in-person examination if a patient calls a third time with a complaint that was not resolved by previous telephone advice.
• Document all calls in which medical information or advice is provided. Documentation should include the date, time, patient’s name, name of caller (as well as his or her relationship to the patient), complaints, concerns, questions, and the advice given. Use teach-back with documentation confirming patient’s understanding.
• Document critical negative information that helped determine the advice 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.”
• Document the reasoning behind any deviations from the written protocols.
• End all calls by providing patient instructions on when to call back or seek emergency care if symptoms worsen or persist.

For more information about communicating effectively, read our article “Telephone Communication for Healthcare Providers: Safety Strategies.” For guidance and assistance in addressing any patient safety or risk management concerns, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.

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