(Excerpted from Medical Economics, 9/5/2008)
The message on the insurance agency's phone system said, "Leaving a message does not bind coverage." Unfortunately, patient messages are not quite as easy to handle. Protecting yourself from liability resulting from after-hours calls requires good communication skills and thorough documentation.
The best evidence for a defense is a progress note or message pad note entered into the chart that explains the nature of the patient's complaint in the telephone call, as well as the advice given by the doctor.
Don't rely on your memory and verbal testimony. It can often deteriorate into a "he said, she said" argument relating to memories that can be faded or biased. A contemporaneous note, on the other hand, is unassailable because it was written when the memory was fresh and there was no reason to be anything but objective.
Ensure that your notes include the date and time, the caller's name (and patient's name, if different), complaint, recommendation (action taken, advice given, medication advised or prescribed), and your signature. Then be sure to place it into the patient's file.
You don't need to make a note for every call, but you will protect yourself if you do it for the more serious calls. Also make sure that your partners document their phone conversations and train your staff to do the same. Start an unwritten, but agreed upon, office policy to use telephone message pads.
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