Documentation of Telephone Contact for Test Results
A telephone consult note is sufficient and should be placed in the medical record, but it does not need to be "appended" to a separate patient note—the telephone encounter itself constitutes a complete, standalone documentation entry. 1
Documentation Requirements
All telephone encounters must be documented in the medical record to ensure continuity of care and demonstrate the complexity of clinical decision-making. 1 The American Academy of Pediatrics establishes that telephone documentation should include: 1
- Date and time of the call
- Patient identification
- Caller's name
- Reason for the call
- Total encounter time
- Relevant history and evaluation
- Assessment
- Plan
- Disposition
Structure of Telephone Documentation
The American College of Physicians recognizes three distinct documentation types in electronic health records: Telephone Encounter notes, Patient Instructions, and Progress Notes. 2 Each serves as an independent, official medical record of patient-provider interactions. 2
- Telephone Encounter notes stand alone as complete documentation and do not require appending to other note types 2
- All documentation should contain metadata including author information, authentication details, timestamps, and document status 2
- Authentication information establishes which provider verified the accuracy of the documentation 2
Clinical Communication Best Practices
When communicating test results by telephone, the documentation should be: 2
- Concise and organized, avoiding excessive or irrelevant information that obscures key findings
- Focused on relevant clinical information specific to that encounter rather than generic templated content
- Sufficient in detail to effectively communicate the patient's clinical situation
Common Pitfall to Avoid
Do not create redundant documentation by both writing a telephone consult note and appending information to a separate progress note. 2 This practice contributes to "note bloat" and can obscure important clinical findings. 2 The telephone encounter note itself serves as the complete record of that interaction and should be filed as a discrete entry in the medical record. 1, 2
Patient Access Considerations
Patients increasingly have electronic access to their medical records, including telephone encounter notes. 3, 4 Documentation should use clear language that empowers patients while maintaining clinical accuracy. 3 When patients read notes about test results, they report feeling better informed and more engaged in their care. 4