One key area of record-keeping that is often overlooked is the documentation of patient phone calls, whether during or after office hours. When dealing with patient phone calls in the office, it is important to have the patient’s chart available to review prior relevant clinical information and document current communication. When calls are received out of the office, especially at an inconvenient moment, such as during the movies, dinner at a restaurant, or in the middle of the night, it is also important to have a process in place to capture timely documentation of the communication. Adequate phone call documentation reflects clinical decision-making, supports actions taken, and provides for safe continuum of care. 

The following claim analyses highlight the lack of documentation of patient phone calls, which played a significant role in the defense of the claim. In each of these cases, the claimant prevailed and significant indemnity payments were made on behalf of the defendant physicians.

Case 1

Claimant was a 77-year-old female who alleged negligent post-operative management of cataract surgery, resulting in permanent loss of vision in her left eye.

Case Summary

(Day 1, Monday) The patient had surgery by Dr. 1 to extract the cataract of her left eye.

(Day 5, Saturday) Patient experienced white spots in vision of left eye and called Dr. 1’s office after hours. Dr. 2 was on call and responded to the patient. Dr. 2 testified that the patient only complained of cloudy and hazy vision (no complaint of white spots). Dr. 2 advised the patient that this was not an emergency and it could wait until her next scheduled appointment in two days. Dr. 2 did not examine the patient or contact Dr. 1 regarding the patient’s complaint. Dr. 2 did not document any notes of the phone conversation with the patient.

(Day 7, Monday) Patient was seen at Dr. 1’s office for next scheduled appointment and on physical exam was found to have reduced visual acuity. Patient informed Dr. 1 she had white spots in vision since Day 5. Dr. 1 diagnosed the patient with Endophthalmitis and immediately referred her to a retina/vitreous specialist, who saw her on the same day and agreed with Dr 1’s diagnosis. The specialist performed a Pars Plana Vitrectomy to administer antibiotics.

(Day 19) Dr. 1 was continuing to follow the patient. Her left eye visual acuity was 20/400.

Outcome

(Three years later) Patient was seen by Dr. 3 and was found to have Ischemic optic atrophy of the left eye, resulting in significant and permanently reduced visual acuity of the left eye.

Risk Issues

There was a question of what exactly the symptoms were that the patient identified to Dr. 2. Documentation of the phone call and the specifics of the call, including the complaint and advice given, could have clarified this in the medical record and prevented a claim from being filed, by supporting Dr. 2’s testimony.

Dr. 2 did not notify Dr. 1 of the patient’s phone call.  Covering or on-call physicians should advise the covered physician about any patient contacts or treatments rendered during the coverage period at the time of the handoff, and document the discussion.

Conclusion

Comprehensive and concise documentation serves first to promote a continuum of care; in addition it demonstrates the process of critical thinking upon which doctors base their actions. It is also important to communicate with the patient’s physician when covering for another physician to ensure everyone involved in the patient’s care is kept informed.

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