In developing On Call Central as an alternative medical answering service, one of the issues we have attempted to address is provider non-compliance as it pertains to the process of documenting patient phone interactions. In research the scope of the problem, we not only spoke with a large number of providers, but looked for peer-reviewed studies examining documentation rates in clinical medicine. The results, quite frankly, are depressing and underscore the need for new methods of ensuring documentation of phone interactions.
Two Peer Reviewed Studies
In contrast to face-to-face interactions occurring during normal office hours, after hours phone calls are documented poorly, if at all. Though the number of studies examining patient/physician phone interactions is small, it seems likely from my recent discussions with providers that the conclusions of two older peer reviewed studies (the abstracts of which I have pasted below) remain accurate today. Emphasis mine below.
The first is a 1989 study by Hamadeh conducted at a single family practice residency program (thanks to Jan Cartwright of the Society of Teachers of Family Medicine for providing access to this now difficult-to-find study):
It is not known how many of the telephone calls received by family medicine residents get documented in a retrievable form. This descriptive study attempted to answer this question by comparing a university telephone operator’s logbook to the files of after-hours encounter slips kept in a university based family medicine training program. Over a period of 10 weeks, 38% of the calls recorded by the operator were documented by residents in a retrievable fashion. Second-year residents documented calls significantly more than third-year residents, and all residents kept better documentation on calls that concerned young children. Documentation varied significantly among individual residents but was not affected by the day or time of calls. These results suggest that having a system for recording after-hours telephone calls is not sufficient to ensure adequate documentation. Monitoring after-hours call records may provide a solution.
A multi-site study by Hannis, et. al., conducted in a sample of internal medicine residents, arrived at similar conclusions:
Little is known about the mechanisms used in internal medicine residency programs to handle patient telephone calls. To address this, a survey of internal medicine residents was conducted at 10 different internal medicine residency programs. The response rate was 76% (N = 388). Approximately 90% of the residents handled patient telephone calls. The residents saw a mean of 7 patients per week in clinic (standard deviation +/- 2) and received an average of 2 patient calls daily (standard deviation +/- 2). The mean number of patient calls received each night on-call was 3 (standard deviation +/- 6) and on weekend call days, an average of 4 patient calls were received (standard deviation +/- 8). Internal medicine residents reported spending an average of 7 minutes per call talking to the patient (standard deviation +/- 5) and 8 minutes in follow-up activities (standard deviation +/- 6). Residents reported documenting calls less than 35% of the time. Residents disagreed with the statements “I am very satisfied with my patient telephone call system” and “My patients are very satisfied with my telephone call system.” Most internal medicine residents handle a significant amount of patient telephone calls, and the systems for handling these calls are less than satisfactory. The procedures used to manage patient calls and the training for this component of practice should be improved.
Conclusions From Studies of Documenting Patient Phone Calls
Collectively these studies suggest several findings:
- Overall documentation rates are awful. With more than 60% of phone interactions going undocumented, there is an unacceptably high amount of risk for both the patient and provider.
- Documentation rates decrease as a provider’s career progresses. The Hamadeh study found that PGY3s documented calls at a significantly lower rate than PGY2s (31% -vs- 42%). While the pace of decline likely decreases over time, my conversations with providers suggests that a small minority of calls are documented, and an even smaller percentage make it into patient charts.
- Manual methods of documentation fail. Providers cannot be reasonably expected to document calls in a manual manner. Automated procedures that document and preserve the interaction are necessary to overcome the degree of provider non-compliance.