Only the physician or an appropriately trained and qualified clinical support person, following written advice protocols that the physician approves, will give advice over the telephone. If possible, the physician or clinical support person should have the patient’s medical records available at that time to review.
Document all advice calls in the patient’s medical record contemporaneously or upon completion of the call. Documentation should include the following:
- Patient’s name (if the caller is not the patient, include the caller’s name as well)
- Date and time of call
- Patient’s question or concern
- Response or advice given
If advice is given to the patient, the patient should be instructed to repeat the information provided by the practice employee and documentation of the same should be recorded in the patient’s medical chart.