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Transcript
Hey guys! In this lesson, I want to give you some insight on what to chart in regards to provider phone calls, like it or not we all have to do it!
So first off I want to point out that your state and facility both most likely will have policies on what they want you to document in regards to provider phones. Guys make sure you know these policies because phone calls are never going to go away this is definitely an important component of the nursing profession.
Before we get into the actual documentation portion of this lesson I want to give you a few “before the call” tips. At some point in your career, you will have to call a provider for a variety of things. This can definitely be an anxiety-producing event until you get used to it….which I promise you will but in the meantime doing a few things can help you out! First and most importantly know your patient! Know their situation including code status, background including history and allergies, assessment findings including vital signs and also their latest lab work. Guys be ready to ask your question especially if you are calling in the middle of the night. And finally always, always have paper and pen ready to go even if you chart in the computer often times phone calls to providers to result in a new order.
Ok so what is important to document? Well, of course, you are going to most definitely document the time the call was made to the provider and also the time the call was returned by the provider if they do not answer when you call the first time. Be sure you document the provider's response.
So I already mentioned that a lot of times a phone call to a provider results in a new order or multiple orders. So what do you document in this instance? Be sure to document the date and time of the order as well as the provider's name, the exact order given, and you are also going to want to document a T.O. which indicates that this order was given by telephone. And guys the provider has to be talking to you, you cannot be getting this information from anyone else besides the provider. Finally, it is crucial that you also document that the order was read back to the provider and verified by the provider.
When it comes to the documentation of provider phone calls it is important that you are accurate but it is also important that you cover yourself. If you are calling a provider that either means that there is an issue or you need clarification on current order. Either way, there is a patient who needs something so time is of the essence which is why it is so important that you always document the time the call was made. So what if the provider doesn’t call back? In this instance, you are going to follow your facility’s chain of command policy and you will not chart “No call back by provider” in the legal chart. Guys be sure you check out our lessons on the escalation of the chain of command as well as the legalities of charting.
Let’s review! Provider phone calls are a part of the job so make sure you know your state and facilities policy on this type of documentation. Before the call knows your patient, have paper and pen handy and be ready to ask your question. Document the time of the call, the time the call was returned, and the response. If an order is given the document the date, time, provider name, the exact order, T.O. for a telephone order, and that the order was read back and verified. Be sure you cover yourself, if the call was not returned follow the chain of command process, do not chart “call not returned.”
A few nursing concepts we can apply to the provider phone calls are clinical judgment, professionalism, and communication as all of these concepts are critical in the process of the documentation of provider phone calls.
We love you guys! Go out and be your best self today! And as always, Happy Nursing!
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