APMA News - November/December 2017 - S3

SUPPLEMENT TO APMA NEWS

YOUR APMA / PAGE 3

TELEPHONE CALLS AND ELECTRONIC COMMUNICATIONS
By Barbara Bellione, RN, CPHRM, ARM, director of Risk Management, PICA

A topic that many times becomes a credibility issue in a lawsuit is whether or not a particular communication took place.
It could be a communication between the patient and his or her podiatrist, between the patient and a staff member,
between a podiatrist and another health-care provider, or between a podiatrist and a staff member.

t is important to document in the patient's
medical record all communication to or
from a patient and all communication
made on behalf of the patient (such as
scheduling tests, referral appointments, etc.)
regarding the patient's care and treatment.
Documentation of phone calls should
include:
* date and time of call;
* the name of the person to whom you
spoke;
* the name and title of the person in your
office making/receiving the call;
* the reason for the call;
* your orders, if applicable;
* advice or information given; and
* appointment offered and/or scheduled,
if indicated.
It is recommended that you review all
messages from patients and advice given by
other staff members for appropriateness and
co-sign to indicate your review and approval
of the advice.
Don't forget to document phone calls you
make or receive after hours. Documentation
can be made in the patient's EHR if you have
access after hours. If not, make sure you
have telephone documentation forms with
you at all times so that you can document
after-hours calls while they are fresh in your
memory. Then once you return to the office,
the telephone documentation form can be
placed or scanned into the patient's medical
record. Alternatively, you can use your notes
to document the call in the medical record,

being careful to document the date you are
making the entry and the date the call actually took place.
Health-care providers are increasingly
communicating with patients electronically.
Electronic communication can be in the
form of email, cell phone calls, texting, social
media, or e-portals. When communicating
with patients electronically, be sure to closely
follow HIPAA privacy and security rules.
A significant concern when communicating with patients electronically is the failure
to include electronic communications in the

patient's medical record. If electronic communications are not included in the patient's
medical record, a situation may arise in which
the podiatrist will not be able to provide proof
of an action or justify his or her medical decisions. Any electronic communication to/from
or concerning a patient should be preserved
for the medical record. Examples include the
texting of orders, providing podiatric advice
to a patient, and scheduling an appointment.
A note regarding electronic communication with patients: It is recommended that
you obtain informed consent from the patient
in order to communicate with him or her electronically or via a personal electronic device.
Because email and texting are so immediate,
patients may come to expect that a podiatrist
will respond within minutes when, in fact, the
podiatrist is not available to respond until the
next day. Accordingly, if a podiatrist chooses
to communicate electronically, there must be
clear disclaimers about response times.
For more information, contact the PICA Risk
Management Department at 800-251-5727
or visit www.picagroup.com.

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Table of Contents for the Digital Edition of APMA News - November/December 2017