According to our closed claims analysis, miscommunication is one of the most common causes of adverse patient events in the physician’s 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 is the process of managing a patient’s call to the office to determine the urgency of the medical issue, the level of provider who should respond, the appropriate location for the patient to be seen (if necessary), and the timing of appointment scheduling. (Note that this process is separate and distinct from the guidelines that practices should develop and implement for visits designated specifically as telehealth encounters.)
Implementing an effective telephone triage system in the office practice can improve physician-patient communications, quality of service, patient satisfaction, and continuity of care—and it can promote optimum clinical results. It can also reduce emergency department (ED) visits while ensuring that the patient has timely access to the appropriate level of care. Telephone triage, however, has its own inherent risks.
Telephone triage requires an accurate assessment of the patient’s concerns without the benefit of a face-to-face visit. For this reason, only licensed professional staff with appropriate training should provide telephone triage.
Clearly define the necessary qualifications and training in the job descriptions of personnel who perform telephone triage. Unlicensed 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 that require an office visit, a transfer to the physician for a more detailed evaluation, or an instruction to call 911 for immediate emergency response. Office staff must have clear guidance and repeated training on situations that require calling 911 for immediate emergency support.
We strongly recommend informing patients in writing about the types of circumstances in which advice may be provided by telephone. Examples include some low-level gastrointestinal complaints and minor headaches, cuts, and bruises.
This information can be posted on the practice website, included in the physician’s welcome packet to new patients, or added to the conditions-of-treatment form the patient signs at the outset of the relationship.
Providing examples in advance of the types of problems that are likely to require an office or ED visit will help patients decide on the most appropriate course to follow. Recommend a face-to-face encounter when a patient or other caller seems overly anxious or dissatisfied with the advice provided or if the patient believes the situation is urgent and requires more immediate and in-depth attention.
Instruct patients to dial 911 in situations that involve (but are not limited to) allergic reactions, chest pain, eye injuries, burns, active bleeding, loss of consciousness, signs or symptoms of infection, 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 line while another staff member calls 911. This will ensure a smooth and seamless transition to the next level of emergency service.
Triage algorithms can assist registered nurses or advanced practice providers in responding to patients and documenting telephone conversations. The physician should review all telephone triage decisions. If a patient needs to be seen in the ED, the physician should contact the ED with a presumptive diagnosis, a description of symptoms, and the information obtained by the practice during the telephone encounter.
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 clinicians.
Advice protocols help registered nurses and advanced practice providers 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. 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 protocols are in accordance with the standards of care and recognized authoritative sources. 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. Unlicensed personnel should never provide telephone advice. To minimize your liability, implement appropriate job descriptions for all categories of office staff, and do not allow staff to act outside the scope of practice.
Document Telephone Interactions
Document all information related to medical advice given over the telephone thoroughly 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 case in which it becomes the patient’s word against the staff member’s or physician’s word. Plaintiff’s counsel will be quick to point out the old adage, “if it’s not recorded, it wasn’t done.”
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 subsequently filed. Regardless of when or where the contact occurs, record telephone interactions in the patient’s medical record promptly.
Patient Safety Strategies
The physician is ultimately responsible for telephone triage and any medical advice provided. Implement the following strategies to minimize risks:
- Utilize 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 physician immediately. The physician 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 doctor 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 their scope of practice.
- Require that staff members refer calls directly to the physician 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.
- 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 Physicians: Safety Strategies.”