The way that we communicate has changed dramatically over the years. Even with the introduction of technology-based communications—such as email, telemedicine, and text—the telephone call is still the most widely used communication tool between physicians and patients. But telephone conversations can present difficulties and may be inherently deceptive because both parties lack the ability to observe nonverbal communication (for example, facial expressions, eye contact, and gestures) that clarify and qualify what the voice is expressing.
When casually or carelessly conducted, telephone communications can lead to diagnostic errors and misunderstandings that may culminate in medical malpractice claims.
Telephone Communication with Patients
Creating comprehensive, clear guidelines for telephone encounters with patients is critical in mitigating risk. Establish practice guidelines and ensure that all office and clinical staff are trained on their roles in communicating with patients by telephone. Protect yourself from potential liability by following these general practices:
- Smile when you greet patients. Research has shown that people are able to tell if you are smiling by the tone of your voice. Warmly express to patients that you are happy to speak with them today. This interaction may be the first impression that a patient has of the practice or of the staff, and it is a factor in patient satisfaction.
- Triage and refer all critical calls to an emergency room. Examples of critical calls include abdominal or chest pain, fever of unknown origin, high fever lasting more than 48 hours, convulsion, vaginal bleeding, head injury, dyspnea, casts that are too tight, visual alterations, and the onset of labor. For more information on this topic, read our article, “Telephone Triage and Medical Advice Protocols.”
- Listen very carefully and pursue questions relevant to the medical problem to help you arrive at an accurate appraisal of the patient’s condition while you are on the phone. Obtain as much information as possible about the patient’s presenting complaint, medical and surgical history, current medications, and allergies. Allow the caller both the time and opportunity to ask questions.
- Speak to patients clearly and slowly, and enunciate carefully. Use easy-to-understand language, avoiding medical terminology. Obtain the services of an interpreter if there is a language difficulty.
- Avoid distractions, such as checking email or attending to other duties, when speaking with the patient. Drowsiness, fatigue, or distraction on the part of either party can affect the ability to communicate effectively.
- Maintain privacy, and be aware of your surroundings and who is around you when you use a mobile phone to speak with a patient outside of the clinic.
- Adhere to HIPAA rules and regulations to maintain patient privacy when communicating over the phone in the office. Use a low voice when discussing protected health information, and implement reasonable safeguards to avoid disclosing information to others not involved in the patient’s care.
- Develop written protocols for front office/nonlicensed personnel to help them respond to patient questions and concerns.
- Prescribe or advise by phone only when you have reviewed the patient’s allergies, medications, and medical and surgical history. If providing new instructions to the patient, such as changing a medication dosage, ask the patient to repeat back the instructions to you to ensure understanding. Document the patient’s understanding in the medical record.
- Accept a third party’s description of a medical condition only when you have confidence in that person’s competence to describe what he or she sees. If descriptions are unclear, the patient may require an office visit.
- Make a prompt referral, and follow up with the referred provider and patient if the patient’s call concerns a medical problem that is outside your specialty.
- Confirm that pharmacists understand all dosages and instructions for drug prescriptions given by phone. Spell out any similar drug names and use individual numbers for dosages, such as “five zero” for 50. Include the reason for the use of the drug. Insist that pharmacists repeat information back to you. Do the same with hospital nurses who take your telephone orders. A safer approach is to use electronic prescribing or fax the medication order.
- Verify and document patient compliance with telephone advice through a follow-up contact to ensure continuity of care.
When you will be away from your own practice or covering for another physician, these additional guidelines may help you avoid problems:
- Implement a communication process between physicians providing cross-coverage. In several instances, a covering physician has been held completely responsible for damages resulting from a telephone misdiagnosis while the original physician was exonerated.
- Provide a brief status report on your acute patients and notice of any anticipated calls when handing off care.
- Provide the physician whose patients you have been covering with documentation of any calls during your coverage period.
- Prescribe only the amount of medication the patient requires during the period you are covering for another physician. Pain medications and narcotics should be refilled or ordered only in small amounts and per state regulations.
When cases are tried, disagreements about what was said during conversations are invariably a major problem. Follow these documentation processes to mitigate this risk:
- Document all phone, email, and text conversations with patients in the medical record—including those received and returned after hours. Include the date and time of each contact and when follow-up is completed.
- Record all details immediately about the information you received, what you advised, and the orders you gave. This action is especially important when a phone call occurs after office hours or on a weekend.
- Implement an office process for calls received during office hours. Office staff should tell the caller when the physician is most likely to return the call. Include tracking and follow-up to ensure that the caller’s questions and problems are resolved and documented.
- Document a patient’s hospital medical record with telephone conversations about the hospitalized patient—including any conversations with nurses.
Effective telephone communication and its documentation are vitally important in preventing and defending litigation. For additional risk reduction strategies, contact the Department of Patient Safety and Risk Management at firstname.lastname@example.org or (800) 421-2368.