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