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Telephone Communication and Triage in the Physician Office (Summer 2010)

By Anthony Volpe, MD, Assistant Medical Director, Medical Director of Professional Liability and Risk Management
Every encounter with a patient influences their perception of the quality of the care they’re receiving. If a patient perceives that they are not receiving quality care this presents a liability.
In most cases, medical practices that lack the ability to communicate effectively have low patient satisfaction. The patient’s perception is compounded by a staff that views the phone as a nuisance. It is extremely important that patient communication via telephone be regarded as equally important as face-to-face communication. Telephone conversations are unreliable by their very nature, and an incomplete evaluation with the rendering of medical advice can make a physician liable for a patient that was never seen. The telephone has become the “front-door” for the patient and a target for liability issues. In a study by Harvey Katz, MD in 2007, faulty triage of calls and errors in the documentation of calls were cited in allegations of failed diagnosis.
The most dangerous first step in the breakdown of patient-physician communication is pushing the hold button. This step, before determining the reason for the call, leads to patient frustration, anger and increased liability or at the least, loss of patient from the practice.
The following recommendations for telephone etiquette are suggested:
a.  Answer phone calls promptly
       i.  Office can establish a policy for proper greeting
b.  Speak slowly
       i.   Patients are under stress
       ii.  Older patients or lack of verbal skills make this step crucial 
       iii.  Be courteous
c.  Give patient your full attention
       i.   Speak in a pleasant tone
       ii.   Smile (mirror by phone helps) – This will be reflected in your voice
       iii.  Convey to the patient you want to assist
d.  If problem is not resolved; inform patient that information will be given to nurse/physician and a return call will follow
        i.  Have a tracking mechanism to assure follow-up occurred
e.  Document the call
        i.  At a minimum:
            1.  Patients’ name
            2.  Name of caller
            3.  Time & Date
            4.  Name of receiver of call
            5.  Phone number to return call
            6.  Reason for call
            7.  Allergies/medication (if pertinent to problem)
            8.  Action taken
                  a.  Return call
                  b.  Nurse/physician notified
                  c.  Appointment given
f.  Hang up gently
g.  Never give advice beyond your competence level/training (see triage section)

The quality of the service will be related to the level of service. Proper triage procedures will improve the quality of care and reduce liability. 

The following recommendations for telephone triage are suggested:
a.  Have procedures and guidelines for staff who field telephone calls
         i.   Establish proper hand-off of call for:
               1.  Urgent problems
               2.  Missed appointments
               3.  Testing
               4.  Consults
               5.  Prescriptions
               6.  Schedule changes
         ii.   Develop message pads for documentation
         iii.  Develop decision grids for proper triage (keep by phones)
b.  Train telephone triage nurse or staff
         i.   Develop office guidelines
         ii.   Encourage patient to come-in, especially after multiple calls
         iii.  Resource management improved by:
                  1.  Reduced unnecessary repeat calls
                  2.  Reduced unnecessary visits
                  3.  Reduced non-compliance
                  4.  Improved care and patient satisfaction
c.  Patient/family not satisfied with information? Schedule patient for a visit
d.  Phone “trees” and prompts are ok, but always have an option to speak with staff
After Hours Calls 
a)  Establish office policy for when calls will be returned (end of day, during day)
         i.   Inform patient 
         ii.  Follow-up to assure calls are returned
         iii.  Multiple calls – same problem – SEE PATIENT!
b)  Beware answering machines or voicemail
         i.  Give no specifics, request recipient contact office
         ii. The fact that the patient came to the office is confidential!
c)  Evaluate the answering service
         i.   Call your own service
         ii.   Are they efficient
         iii.  Are they courteous
         iv.  Are they accurate
         v.   Are they putting you on HOLD!!
Document… Document… Document… A major obstacle in a liability case is disagreement in what was said. Whenever any doubt arises, schedule the patient for a visit.
      Office Telephone Assessment Form
      Telephone Message Form
      Telephone Utilization Form

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