General Question for the Week of June 26, 2017

General Compliance Question of the Week

Question:

What are Medicare rules on documentation of physician-patient telephone calls?

Answer:

From a medical malpractice perspective, documenting telephone conversations with patients or their family is just as important as documenting face-to-face encounters. When the physician or any member of the staff talks to a patient regarding a clinical issue, document the following:

  • The date of the call
  • The time of the call
  • The patient’s chief complaint
  • Any additional information received from the patient to elucidate his/her condition
  • Any treatment recommendation (e.g., coming to the office, presenting to the emergency room, contacting another physician)
  • Any medications (over-the-counter or prescription)
  • The date and time a prescription was called in and the phone number of the pharmacy
  • The date that the patient is to return for care
  • The name and signature of the individual who performed the service.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.