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IDEAS THAT WORK
LET IT BE WRITTEN, LET IT BE DONE
Document Telephone Contacts
With Patients
W
e're all familiar with
the saying, "If it wasn't documented, it
wasn't done." While it's important
to take patients' complaints very
seriously — and to notify the
physician immediately when they
portend potentially major problems— it's also important to properly document patient telephone
calls in the clinical record. All too
DOCUMENT THE MEDICAL RECORD
The "wasn't documented, wasn't done"
motto applies to patient phone calls.
often, while reviewing clinical records during accreditation surveys, I'll
see Post-It Notes or telephone memo sheets stuck into the pages of the
clinical record and no documentation of that information within the
record itself. These small pieces of paper can easily fall out and are
usually discarded when scanning the records for electronic storage.
Any telephone communication has a potential liability risk if not properly documented and followed up on.
Jack Egnatinsky, MD
President, AAAHC Board of Directors
jackegnatinsky@gmail.com
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O U T PAT I E N T S U R G E R Y M A G A Z I N E O N L I N E | N O V E M B E R 2012
