Clinical Call Documentation

What Works: Effective Practices for Office-based CareTelephone Triage
Documentation of Clinical Calls

Recommendation: Clinical phone calls in which medical information is discussed are documented in the patient's medical record with the date and time, essence of the problem, and advice given.

Source: CRICO/RMF Office Practice Handbook


 Exemplary Practice

Developing "smart text" telephone triage algorithms to assist RNs in appropriate documentation of telephone conversations

Benefits:
  • Standardized format includes documentation prompts
  • Documented directly into an electronic system
In practice at: Medford Internal Medicine Practice (HVMA), CHA (most sites)


 Effective Practice
  • A two-part form used to document clinical telephone calls.
  • A copy is placed in the patient's record.
Benefit: Low tech encourages documentation in the medical record.
In practice at: Common Practice


 Effective Practice
A logbook to document patient phone calls
Benefits:
  • Provides documentation standardization
  • Ability to track and trend triage calls
In practice at: Brigham and Women's Physician's Group (BWH), Southern Jamaica Plain Health Center (BWH)


 Effective Practice
Nurses use a two-part telephone contact form, with prompts to help themobtain pertinent information and actions taken
Benefits:
  • Contains prompts for complete documentation
In practice at: Neponset Health Center (BWH), Mount Auburn Medical Associates (CareGroup)


 Effective Practice
Adhesive backed forms
Benefit: Easy filing in the medical record
In practice at: Family Medicine Shrewsbury (UMass)


 Effective Practice
  • A standardized message form that includes the date and time of the call, as well as the nature of the medical issue
  • This form is routinely documented in the medical record
Benefit: Provides documentation standardization
In practice at: Newton-Wellesley Internists (NWH), Brigham and Women's Physician's Group (BWH)


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