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Document Conversations

Completion requirements

The following tips can help establish call documentation protocols at your practice:

Be Proactive Regarding Call Documentation By Developing A Policy And Corresponding Procedures

Train staff members in telephone protocols and authorize them to interrupt the provider as necessary.

Provide nonclinical personnel with guidelines to appropriately respond to emergency/urgent care concerns.

Be Specific
  • Record the content of the call in the customer’s record.
  • Include any advice/instructions provided and the customer’s understanding of that information.
  • Include the name of the staff person who took the call in, addition to customer’s requests, concerns and issues.
  • Document all follow up conversations and calls concerning previously discussed problems, recommendations and test results in a timely manner.
  • Document calls and conversations with family members (including the name of the person who called and their relationship to the customer) and relay this information to the provider or designated staff member.
  • Rather than having a customer call the provider back, have the provider or designated staff member return the call.
  • Advise the customer of approximately when they may receive a call back, from whom, and confirm the number to reach them at that time.

Periodically Review The Telephone Responses And Documentation To Bring To Light Situations In Which Additional Staff Training Or Policy Revisions May Be Required

You should never feel that call documentation clutters your records. Instead, consider call documentation to be an essential opportunity for documenting your communications with customers. This will help lead to a complete and accurate record.