General Question for the Week of June 26, 2017

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.