Office nurse- charting phone calls with patients

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    I've been an R.N. since 1995. All my experience has been inpatient labor and delivery. I took some time off to be with my kids at home and have recently returned to work as an office nurse for an Ob-Gyn. I am the 1st R.N. he has hired. His other staff members are M.A.s. I took my 1st phone call from a pt. the other day. It was not a serious matter. My inclination was to chart what her concern was and my response. I double checked with the MA that was working with me that day and she said it was not necessary to chart it at all. She said they take so many phone calls that there is no time to chart all the calls. I disagreed with her and took the time to chart it anyway. My question to other office nurses is this... do you chart all phone calls from your patients? Also, if anyone knows of a good book or resource for nurses who do a lot of "assessments" over the phone (like from nervous pregnant women), or for telephone triage nurses, I'd appreciate the name of it. Thanks!
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    I think you did the right thing. I do not work in an office but a small hospital ( 26 beds) and we field many calls from families.Most of our pts are elderly and have POAs with concerns. We try to chart most family interactions, including phone calls. Once we had an irate family member of a recently deceased pt. complain that we had not notified him of the pts declining condition.Luckily the RN in charge had documented her conversation with this person.
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    I work in an office and I chart all my phone calls with patients. The only exception to that would be, for example, if someone is calling because they know their appointment is on Tuesday, but forgot what time they are supposed to be there. However, if I make a new appt. I would chart that.

    I absolutely write down patient care and advice that I give. I also try to write down what symptoms the pt. doesn't have, if it would save my butt in the future. For instance if the pt. is making an appt. for leg pain, I ask and then write down that this is not sudden, accompanied by no swelling, their feet aren't cold, etc. Basically it is proving that I didn't miss a blood clot. This has saved my job. The doctor I work for has tried to accuse me of a number of different things related to pt. phone calls, but I've always had documentation to back me up. Obviously, try to write things concisely and use appropriate abbreviations (more are allowed in a private practice than JCAHO lets you get away with in the hospital).

    Good luck and CYA!
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    Almost forgot . . . I use "Telephone Triage Protocols for Nurses" by Lippincott. Great resource that I keep by my desk at all times.
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    Quote from STNA
    I work in an office and I chart all my phone calls with patients. The only exception to that would be, for example, if someone is calling because they know their appointment is on Tuesday, but forgot what time they are supposed to be there. However, if I make a new appt. I would chart that.

    I absolutely write down patient care and advice that I give. I also try to write down what symptoms the pt. doesn't have, if it would save my butt in the future. For instance if the pt. is making an appt. for leg pain, I ask and then write down that this is not sudden, accompanied by no swelling, their feet aren't cold, etc. Basically it is proving that I didn't miss a blood clot. This has saved my job. The doctor I work for has tried to accuse me of a number of different things related to pt. phone calls, but I've always had documentation to back me up. Obviously, try to write things concisely and use appropriate abbreviations (more are allowed in a private practice than JCAHO lets you get away with in the hospital).

    Good luck and CYA!
    I think you are correct in being so thorough in your charting. I probably could not keep up with the amount of charting of phone calls that you are doing. I guess it gets easier the more you do it.
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    I agree with previous posters and with what you did. Definitely chart. Iím not a nurse yet, but this is something I do know about. Iím a medical transcriptionist who has a client whoís an OB/GYN. I donít do his "regular" transcription but his medicolegal work. He acts as an expert witness in many malpractice cases. I canít tell you the number of times a nurse and/or the practice doctor has had their butts saved because telephone calls were properly documented. Lack of such documentation results in a "he said, she said" situation and can get extremely messy. Sometimes the plaintiff seems to have forgotten all about a telephone call, but its existence ends up changing the whole outlook of the case and often results in my client pretty much saying that thereís no case to answer. I often hear about telephone calls to pharmacies too, and they can be relevant in some cases.

    Bottom line is, document, document, document. I have a sneaking suspicion youíre heard that mantra before. :wink2:

    Of course, it could work against you, but only if you werenít practicing safe in the first place.

    Keep on doing what youíre doing and stop doubting yourself. Itís not the MAís license thatís on the line.
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    Document everything. I was an office nurse for 10 years for a busy family practice doctor. I documented everything patients said--positive and negative. Patients don't realize that nurses do this and feel like they can be honest with us more than the doctors. I had patients tell me they took their meds whenever they felt like it--once a patient tried to sue my doctor because he had a stroke from the med he was supposed to be taking but wasn't--when his lawyer reviewed his medical records, the lawsuit was dropped. He knew there was no way a judge would side with him when he had admitted what he was doing. Another time a patient on w/c said he helped a friend move a 300 pound entertainment center. He then tried to tell his work that it was work related--his work subpoened his medical records and refused his claim. Documentation can cya as well as your doctors.
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    I don't work in a doctor's office, but on my job we are required to document all phone calls with family, concerning our residents, whether they call us or we call them.
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    You should make notes of all your calls. When my mother had cancer, she was cared for at MD Anderson hospital in Houston. They had a log book and when patients called they logged in the call, answer provided etc, The slip was torn off for placement into the patients chart and the yellow copy was left in the call log book. I think this is VERY IMPORTANT any time you are giving any kind of advice on the phone. I work on a med surg floor and if a discharged patient calls me for assistance after discharge, I make a note of it on a progress note and send it to medical records for placement into their file.
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    Thanks everyone! I had a feeling my instinct to chart the call was right. I'll keep it up!


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